PREOPERATIVE TOPICAL NONSTEROIDAL ANTI-INFLAMMATORY DRUGS IN THE PREVENTION OF INTRAOPERATIVE FLOPPY IRIS SYNDROME: A REVIEW ARTICLE

Intraoperative floppy iris syndrome is a form of small pupil in which the iris becomes flaccid and billows with irrigation currents, prolapses toward the incisions, and constricts progressively during cataract surgery. It is most strongly associated with tamsulosin, an alpha-1A adrenoceptor antagonist, and it prolongs surgery and raises the risk of intraoperative complications. Standard dilating drops often fail in affected eyes because the iris dilator muscle is pharmacologically impaired. However, part of the pupil constriction seen during surgery is driven by prostaglandins released in response to surgical trauma. Topical nonsteroidal anti-inflammatory drugs inhibit cyclooxygenase, reduce prostaglandin synthesis, and are used routinely before cataract surgery to maintain mydriasis. This review summarizes the pathophysiology of intraoperative floppy iris syndrome, the pharmacology of the available topical agents (flurbiprofen, ketorolac, diclofenac, bromfenac, and nepafenac), and the clinical evidence for their use. Randomised and comparative studies in cataract surgery show that ketorolac, nepafenac, and bromfenac help to maintain pupil diameter, and head-to-head comparisons favor ketorolac and nepafenac over flurbiprofen. Direct evidence in patients at risk of the syndrome comes mainly from intracameral phenylephrine-ketorolac, which reduced iris prolapse and billowing in men taking tamsulosin. No high-quality trial has tested preoperative topical nonsteroidal anti-inflammatory drugs alone against placebo for preventing the syndrome itself. These drugs are best regarded as a low-risk adjunct within a multimodal strategy that also uses atropine, intracameral epinephrine, viscoelastic agents, and mechanical pupil expansion when needed.