a-adrenergic receptor antagonists areused to relax smooth muscle of thelower urinary tract, for relief of

symptoms of benign prostatic hyper-plasia. They cause pupil hypotony(Parssinen 2005) and the triad of

Sub-Tenon injection of 2% lidocaine preventsintra-operative floppy iris syndrome (IFIS) inmale patients taking oral a-adrenergicantagonists

Anna Klysik1 and Dorota Korzycka2

1Department of Ophthalmology, Medical University of Lodz, Lodz, Poland2Department of Ophthalmology, Hospital of the Ministry of Internal Affairs and Administration, Lodz, Poland

ABSTRACT.

Purpose: To compare 2% sub-Tenon and 1% intra-cameral lidocaine for cata-

ract surgery in relation to the incidence and severity of IFIS. Prospective ran-

domized clinical study.

Methods: From 81 eligible, we included 71 men aged from 59 to 90 years

(mean 76.5 ± 6.8) undergoing routine cataract surgery and taking oral a-

adrenergic antagonists, for urological reasons, for more than 1 year. Following

randomization 34 men, aged from 62 to 90 years (mean 77.4 ± 8.1) received

sub-Tenon injection of 2.5 ml of 2% lidocaine and the remaining 37 men aged

from 59 to 89 years (mean 75.2 ± 7.2) received 1% preservative free intra-

cameral lidocaine. Outcome measures were the incidence of IFIS, severity of

intra-operative pupillary constriction and iris prolapse.

Results: Intra-operative floppy iris syndrome (IFIS) was noted in 3 of 34

patients (8.8%) receiving sub-Tenon lidocaine and in 18 of 37 patients (48.6%)

receiving intra-cameral lidocaine (p = 0.00). Severe IFIS was observed only in

3 of 37 patients (8.1%) receiving intra-cameral lidocaine. Pupil diameter at the

end of surgery was 4.37 ± 1.07 mm in the sub-Tenon lidocaine group and

4.02 ± 1.06 mm in the intra-cameral lidocaine group (p = 0.00). Iris prolapse

was noted in two cases in the sub-Tenon lidocaine group and in 10 cases in the

intra-cameral lidocaine group (p = 0.00). Twenty-five patients were receiving

tamsulosin. The incidence of IFIS in tamsulosin subgroup was 76.9% (10 of 13

patients) in the intra-cameral lidocaine group and 16.6% (2 of 12 patients) in

the sub-Tenon lidocaine group (p = 0.00).

Conclusion: Sub-Tenon lidocaine reduces significantly the incidence of IFIS in

patients taking oral a-adrenergic inhibitors as compared with intra-cameral

lidocaine.

Key words: cataract surgery – intra-operative floppy iris syndrome (IFIS) – iris prolapse –

postoperative complications – pupillary diameter – sub-Tenon’s anaesthesia

Acta Ophthalmol. 2014: 92: 535–540ª 2013 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

doi: 10.1111/aos.12205

intra-operative symptoms consistingof progressive pupillary constriction,iris floppiness in response to irrigat-ing fluids and iris prolapse, calledintra-operative floppy iris syndrome(IFIS) (Chang & Campbell 2005).Chronic use of a-adrenergic antago-nists may also cause permanent thin-ning of the iris dilator muscle (Prataet al. 2009; Santaella et al. 2010).IFIS causes surgical difficulty (Tak-maz & Can 2007). Only when it isanticipated, and in an experiencedsurgeons’ hands, the rate of seriouscomplications does not rise signifi-cantly (Chang et al. 2007).

Although this syndrome is multifac-torial, there is a strong associationwith the chronic use of a-receptorantagonists (Neff et al. 2009), espe-cially tamsulosin which is a selectivea-1-AR antagonists (Chatziralli & Ser-gentanis 2011; Chatziralli et al. 2012).

Various preoperative and intra-operative measures have been demon-strated to be effective in dealing withthe condition, as discontinuation ofthe a-antagonist has little effect, andis not always practicable. Preoperativemaximum pupillary dilatation withatropine 1% twice daily for 10 days,has been proposed by Bendel & Phil-lips (2006), also 1% atropine threetimes daily for 2 days preoperativelycombined with intra-cameral epineph-rine was demonstrated to be effective(Masket & Belani 2007). Intra-cameralinjections of phenylephrine combinedwith iris hooks, whenever necessary,has been tried with success (Manvikar& Allen 2006). Intra-operative surgical

Acta Ophthalmologica 2014

535

techniques suggested previously todeal with floppy iris were: soft-shelltechnique with low flow, use of visco-adaptive agent, pupil expansion ringsand iris retractors and capsular stain-ing (Goldman & Karp 2007).

Lidocaine has mydriatic effect(Lincoff et al. 1985), apart from itsanaesthetic and anti-arrhythmic prop-erties. Mydriatic properties have beenreported with intra-cameral use (Cion-ni et al. 2003) and with sub-Tenoninjection (Savino et al. 2010; Ahnet al. 2012). Mydriatic propertiesdepend on the route of administrationand the amount injected.

One percentage preservative-free,intra-cameral lidocaine causes immedi-ate mydriasis, about 5.5 mm anddiminishing in 10–15 min (Oberg et al.2012). When 2 ml of 2% lidocaine isinjected into the sub-Tenon space,mydriasis begins in 2–6 min, is over8 mm, and lasts more than 1 hr (Ahnet al. 2012).

Sub-Tenon lidocaine provides anal-gesia while remaining free of seriouscomplications (Ruschen et al. 2005).Superiority of sub-Tenon technique inpain relief over intra-cameral tech-nique has been demonstrated by Davi-son et al. (2007).

Sub-Tenon anaesthetic techniquehas better safety profile than peri-bul-bar and retro-bulbar injection (Briggset al. 1997). Following sub-Tenoninjection, local anaesthetic solutionhas been demonstrated to accumulatein the sub-Tenon space, behind theglobe, which is traversed by short andlong ciliary nerves (Khandwala et al.2008).

In view of the fact, that mydriaticeffect of lidocaine is different, whenadministered intra-camerally or intothe sub-Tenon space, and also thatlidocaine dilates the pupil in themechanism that does not involve sym-pathetic and parasympathetic recep-tors, like traditional mydriatics, weassumed the symptoms of IFIS maybe influenced, depending on whether1% intra-cameral or 2% sub-Tenonlidocaine is used.

We undertook randomized clinicaltrial of 2% sub-Tenon lidocaine ver-sus 1% intra-cameral lidocaine inpatients taking oral a-antagonists,with less than full pupillary dilatation,to establish whether it has a beneficialeffect of the incidence and severity ofIFIS.

Materials and Methods

Eighty-one men, receiving oral a-receptor antagonists for urinary tractsymptoms for more than 1 year, werereferred to the Department of Oph-thalmology of the Hospital of theMinistry of Internal Affairs andAdministration in Lodz (Poland) forroutine cataract extraction, betweenMarch 2010 and November 2011.Nine patients were excluded, one forprevious iritis, two for previous intra-ocular surgery, one for rubeosis iridis,one for previous ocular trauma andfour because of small pupil. Onepatient refused to participate.

We included 71 eyes of 71 men agedfrom 59 to 90 (mean 76.5 ± 7.1)using a-antagonists for urinary tractsymptoms for at least 1 year prior toplanned routine phacoemulsificationwith dilated pupil size between 4 and8 mm. All patients underwent plannedphacoemulsification cataract surgerybetween March 2010 and November2011. The patients were receiving:tamsulosin, doxazosin, alfuzosin andterazosin.

Numbers of patients receiving eachdrug are summarized in Table 1.None of the patients discontinuedtheir medication prior to planned cat-aract surgery.

Seventy-one eyes of 71 patientswere randomized by tossing a coin onentering the operating theatre intotwo groups. Thirty-four men, agedfrom 59 to 89 (mean 76.4 ± 6.2) hada sub-Tenon analgesia with 2.5 ml. of2% lidocaine and remaining 37 men,

aged from 62 to 90 (mean 76.9 ± 7.9)had topical analgesia in the form twodrops of 2% proparcaine preopera-tively, combined with 1% preserva-tive-free lidocaine intra-camerally atthe beginning of the surgery.

Study was approved by the EthicsCommittee of the Medical Universityof Lodz and conducted according tothe tenants of Helsinki Declaration.All patients gave their full informedconsent.

Exclusion criteria

We excluded patients with previousintraocular inflammation; anterior andposterior uveitis, complicated by irissynechia or not (one patient), historyof previous intraocular surgery (twopatients), patients with zonule dehis-cence and white or traumatic cataractswere also excluded (one patient) aswell as patients with iris neovascularization from any cause (onepatient). We excluded patients withhard cataracts (nuclear sclerosis grade‡3 in the 4-point scale), as this factoron its own would prolong the dura-tion of an operation and increaseintra-operative pupillary constriction.

We excluded four patients withpupils of <4 mm, following adminis-tration of 1% atropine, as thesepatients would almost certainlyrequire usage of mechanical devicesuch as iris hooks or Malyugin ring.Usage of mechanical dilating device atthe beginning of surgery, to obtainadequate pupil size, would not allowthe observation of the iris behaviour

Table 1. Characteristics of the patients in the study.

Intra-cameral

lidocaine group

(Total 37 patients)

Sub-Tenon

lidocaine group

(Total 34 patients)

p-Value

(Chi-squared

and Fisher’s

exact test)

Age 75.2 ± 7.2 77.4 ± 8.1 0.11

Type of drug

Tamsulosin 13 of 37 (35.1%) 12 of 34 (35.3%) 0.45

Doxazosin 12 of 37 (32.4%) 14 of 34 (41.2%) 0.56

Alfuzosin 6 of 37 (16.2%) 3 of 34 (8.8%) 0.42

Terazosin 6 of 37 (16.2%) 5 of 34 (14.7%) 0.51

Coexistent diseases

Diabetes mellitus 8 of 37 (21.6%) 6 of 34 (17.6%) 0.75

Pseudoexfoliation 7 of 37 (18.9%) 6 of 34 (17.6%) 0.85

Hypertension 24 of 37 (64.8) 26 of 34 (76.5%) 0.07

Pupillary measurements

Before surgery 5.61 ± 1.05 5.52 ± 1.07 0.65

After hydrodissection 5.33 ± 1.01 5.31 ± 1.02 0.46

After phacoemulsification 4.21 ± 1.02 4.71 ± 0.96 0.05

At the end of surgery 4.02 ± 1.06 4.37 ± 1.07 0.00

Acta Ophthalmologica 2014

536

and pupil size measurement duringthe operation.

None of the patients had refractiveerror of more than three dioptries ofmyopia or hypermetropia. Patientswith pseudoexfoliation and diabeteswere not excluded. Coexistent diabe-tes, hypertension and pseudoexfolia-tion are summarized in Table 1.

Preoperative assessment

Full medical history was obtained,and ophthalmological examinationwas performed.

Coexistent diabetes mellitus, hyper-tension and pseudoexfoliation werenoted. Drug history was recorded withspecial attention to a-receptor antago-nists, antihypertensive medication andnitrates.

Nuclear sclerosis was subjectivelygraded in the 4 point scale, followingassessment of the nuclear colour andnuclear opalescence as in the LOCSsystem (Chylack et al. 1993). None ofthe patients had brunescent nucleus.Refractive error and iris colour werenoted. Fifty-one of the 71 (71.8%)patients had blue irides and theremaining 20 (28.1%) had dark irides.

Pupillary diameter was measured45 min after two doses of 1% atro-pine, second drop within 15 min fromthe first dose. No phenylephrine wasused at the preoperative assessment.We included all the patients in whomwe considered that pupil did not fullydilate, but was more than 4 mm inhorizontal diameter. The largest pupilwe included was 8.0 mm.

Sub-Tenon injection technique

Topical Proparcaine (Alcon labs.,Alcaine) was used for topical analge-sia. The patient was asked to look up,to expose the lower nasal scleral quad-rant, under the operating microscope.Conjunctiva was opened with sharptip scissors. Tenon’s capsule wasopened. Sub-Tenon space was identi-fied and widened. A blunt sub-Tenoncanula mounted on the 5.0 ml syringewas placed 15 to 20 mm deep into thesub-Tenon’s space, and around 2.5 mlof 2% lidocaine, without hydrolasewas injected over 10 to 15 seconds.The width of the speculum openingwas reduced slightly, to cover theinjection site. Surgical procedure wascontinued without delay.

Intra-cameral anaesthetic technique

Topical Proparcaine (Alcon) was usedfor topical analgesia. Paracenthesiswas performed with 15� blade. 0.2 mlof 1% preservative-free lidocaine wasinjected intra-camerally. No intra-cameral epinephrine nor phenyleph-rine was used.

Intra-operative evaluation

The occurrence of floppy iris wasnoted and graded as no IFIS, mild,moderate and severe IFIS, followingthe criteria accepted by Chang andOsher in their multicentre survey. Thiswas carried out by one assistant(AK), to eliminate interobserver vari-ability in recognizing and gradingIFIS. The assistant entered the theatreat the moment of performing the cor-neal incision and was blinded to theresult of randomization. In few caseswere sub-Tenon injection was compli-cated by a small subconjunctival leak-age of anaesthetic solution, it wasimpossible to blind the assistant.

Tendency to iris prolapse, if itoccurred was graded as mild and pro-found. Significant meiosis wasrecorded when pupillary constrictionexceeded 3 mm during the operation.Total operating time, including sub-Tenon injection, was recorded, by thetheatre technician using stopwatch.

Pupil diameter was measured hori-zontally with calipers, by an assistant,so the total operating time was notprolonged. We recorded pupil diame-ter at the beginning of surgery, afterhydrodissection, at the end of phaco-emulsification and at the end of sur-gery.

All procedures were performed byone experienced surgeon (DK). Supe-rior clear corneal tunnel incision wasperformed, viscoelastic substance(Viscoat, Alcon labs.) was injected, toperform circular continuous capsu-lorhexis followed by phacoemulsifica-tion (Legacy Alcon System, Alcon),implementing the phaco-chop tech-nique. Flow rate was 33 ml ⁄min,vacuum at 350 mmHg for phacoemul-sification and 450 mmHg for irriga-tion-aspiration and viscoelasticremoval. Power was 40% with 2pulses per second.

In an event of IFIS, we were pre-pared to use one or more of the fol-lowing techniques: soft shell with

reduced flow, iris hooks, intra-cameralepinephrine or Malyugin ring. In threecases of iris prolapse, Provisc (Alcon)was used with reduced flow rate andbottle height.

All intra-operative complicationswere noted: torn capsulorhexis andposterior capsule rupture, vitreousloss, iris trauma and hyphema.

Postoperative evaluation

All the patients were examined at1 day, 1 week and 1 month followingcataract surgery. At each postopera-tive visit, complications including:increased intraocular pressure, cystoidmacular oedema, persistent uveitis,persistent corneal oedema, if presentwere recorded.

Iris transillumination defects werenoted: pupil distortion, posterior syne-chia, iridodialysis, iris stromal tearsand permanent mydriasis. Final visualacuity was recorded 1 month post-operatively.

Statistical analysis

We assumed the overall incidence ofIFIS among patients receiving orala-inhibitors with the pupil not fullydilating will be between 50% and60% (Chang & Campbell 2005). Wetested the hypothesis that 2% sub-Tenon lidocaine influences the inci-dence of IFIS. We assumed 20%reduction in the incidence of IFISwould be regarded as significant.Assuming, 90% power of the study,and p £ 0.05, gave us estimated sam-ple size of 39 patients in each group.Preliminary results revealed 40%reduction in the overall incidence ofIFIS and 60% reduction in the tam-sulosin subgroup, so we terminatedthe study. The data were analysed bymeans of descriptive statistics, andFisher’s exact test and chi-squared testwere used for significance. In allanalyses, statistical significance wasconsidered achieved at a value ofp £ 0.05.

Results

Both groups of patients were homoge-nous in relation to age (p = 0.11).Nuclear sclerosis grade was 1.68 ±0.34 in the sub-Tenon lidocaine groupand 1.73 ± 0.38 in the intra-camerallidocaine group (p = 0.76). There

Acta Ophthalmologica 2014

537

were no statistically significant differ-ences in proportion of dark and blueirides in both groups.

Mean pupillary diameter at preoper-ative assessment was 5.52 ± 1.07 mmin the group of patients randomized tosub-Tenon lidocaine injection and5.61 ± 1.05 mm (p = 0.562) in theintra-cameral lidocaine group.

Total surgical time was 10.48 ±3.04 min. in the sub-Tenon lido-caine group and 10.62 ± 3.04 min.in the intra-cameral lidocaine group(p = 0.85).

None of the patients received addi-tional intra-cameral injection of epi-nephrine. We did not use mechanicalpupil dilating devices (iris hooks andMalyugin ring) in any case.

In three cases of severe iris pro-lapse, we used Provisc (Alcon) injec-tion to control iris prolapse, reducedthe bottle height and flow rate. Preop-erative and intra-operative pupillarymeasurements are summarized inTable 1.

Incidence of IFIS

In the group of patients receiving sub-Tenon lidocaine, the incidence of IFISwas 8.8% (3 of 34 patients) and in thegroup of patients receiving intra-cam-eral lidocaine was 48.6% (18 of 37patients) (p = 0.00).

Incidence of IFIS among patientsreceiving oral tamsulosin was 76.9%(10 of 13 patients) with intra-camerallidocaine and 16.6% (2 of 12 patients)in the group receiving sub-Tenon lido-

caine (p = 0.00). The incidence ofmild, moderate and severe IFIS issummarized in Table 2.

In the group of patients receivingsub-Tenon lidocaine, we noted onlytwo cases of mild tendency to iris pro-lapse (2.9%, 2 of 34 patients), and inthe intra-cameral lidocaine group,three cases of profound tendency toiris prolapse and seven cases of mildtendency towards iris prolapse(27.0%,10 of 37 patients) (p = 0.00).

Only in intra-cameral lidocainegroup, we noted three cases of severeintra-operative pupillary constriction.Tendency to iris prolapse is summa-rized in Table 2.

In the group of patients receivingsub-Tenon lidocaine, no serious caseof floppy iris associated with iris pro-lapse and pupillary constriction wasobserved.

There was no statistically significantdifference in the pupil size at the startof surgery between the two groups,but statistically significant differencewas noted at the end of phacoemulsifi-cation (p = 0.05) and at the end ofsurgery (p = 0.00).

Intra-operative complications

No case of posterior capsule ruptureor vitreous loss was encountered. Nocase of serious iris trauma was noted.

Postoperative complication and results

Transient cystoid macular oedemawas noted during the first postopera-

tive week, on the slit lamp examina-tion with +78D lens, in two cases inthe sub-Tenon lidocaine group (2 of34 patients) and in one case (1 of 37patients) in the intra-cameral lidocainegroup. The difference was not statisti-cally significant (p = 0.46).

Postoperative iris transilluminationdefect was noted in one patient in thesub-Tenon lidocaine group and in 10patients in the intra-cameral lidocainegroup. Final best corrected visual acu-ity was 0.5 or better in 32 of 34patients receiving sub-Tenon lidocaineand in 34 of 37 patients in the intra-cameral lidocaine group (p = 0.46).Causes of less than full visual acuitywere dry AMD,and amblyopia.

Discussion

In our study, injection of 2.5 ml. of2% lidocaine into the sub-Tenon’sspace has reduced significantly theincidence of all three features of intra-operative floppy iris syndrome: billow-ing of the iris stroma, the tendency toiris prolapse and intra-operative pupil-lary constriction, as compared with1% intra-cameral lidocaine.

Lidocaine causes mydriasis, whichis not sympathetic and parasympa-thetic receptor mediated (Savino et al.2010). It acts by blocking the initia-tion and propagation of the actionpotential, by preventing the voltage-dependent increase in sodium conduc-tance via a direct action on sodiumchannel, and to a lesser degree by sta-bilizing membranes. It blocks conduc-tion in sympathetic, parasympathetic,motor and sensory nerves.

This alternative mechanism of pupildilatation may gain clinical signifi-cance in situations, where standardreceptor-mediated mydriasis is com-promised, which is in patients receiv-ing a-antagonists. Mechanism ofmydriasis in sub-Tenon lidocaineinjection is probably ciliary nerves,and ciliary ganglion block (Savinoet al. 2010).

Optic nerve conduction block maycause additional suppression of thelight reflex. It may also be a factorcontributing to the maintenance ofmydriasis.

The mydriatic effect of sub-Tenonlidocaine is prolonged, on the con-trary to the intra-cameral injection oflidocaine. Intra-cameral use impliesthat only small volume is injected into

Table 2. The incidence of IFIS and iris prolapse.

Intra-cameral lidocaine

(37 patients)

Sub-Tenon lidocaine

(34 patients)

p-Value (Fisher’s

exact test)

Incidence of IFIS

No IFIS 19 of 37 (51.4%) 31 of 34 (91.2%) 0.0002

Mild 8 of 37 (21.6%) 2 of 34 (5.9%) 0.0439

Moderate 7 of 37 (18.9%) 1 of 34 (2.9%) 0.0329

Severe 3 of 37 (8.1%) 0 of 34 (0.0%) 0.1359

Overall IFIS 18 of 37 (48.6%) 3 of 34 (8.8%) 0.0002

Incidence of IFIS in relation to the drug used

Tamsulosin 10 of 13 (76.9%) 2 of 12 (16.6%) 0.0036

Doxazosin 4 of 12 (33.3%) 1 of 14 (7.1%)

Alfuzosin 3 of 6 0 of 3

Terazosin 1 of 6 0 of 5

Iris prolapse

Mild 7 of 37 (18.9%) 2 of 34 (5.9%) 0.0416

Severe 3 of 37 (8.1%) 0 of 34 (0%) 0.1359

Iris prolapse in the Tamsulosin subgroup

Mild 3 of 13 1 of 12 0.2713

Severe 3 of 13 0 of 12 0.1243

Acta Ophthalmologica 2014

538

the anterior chamber, and immedi-ately washed away with viscoelasticsubstance. Mydriasis with intra-cam-eral lidocaine is brief and diminishestowards the end of phacoemulsifica-tion (Oberg et al. 2012). In the sub-Tenon technique, the site of action isbehind the globe (Khandwala et al.2008), where the fluid accumulates.

Our choice of sub-Tenon techniqueto obtain an autonomic block wasbased on safety considerations (El-Hindy et al. 2009). Among other localinjection techniques, like peri-bulbarand retro-bulbar technique, sub-Tenon injection has the best safetyprofile regarding serious complica-tions, like globe perforation, leakageof the anaesthetic solution into thesubdural space or optic nerve trauma.

We aimed to eliminate other poten-tially confounding factors, whichinfluence the duration of the opera-tion, and present an extra difficulty initself: hard or mature cataract, irissynechia and large refractive error.

a-adrenergic inhibitors influencepupil size in different lighting condi-tions and also cause diminished pupil-lary dilatation (Parssinen et al. 2006;Theodossiadis et al. 2012). Less thanfull pupillary dilatation is also goodpredictive factor for IFIS (Casuccioet al. 2011); therefore, we aimed toselect for the study patients with lessthan full pupillary dilatation on thepreoperative assessment.

Hypertension but not diabetes hasbeen shown to influence the incidenceof IFIS (Neff et al. 2009). In our study,both diabetes and hypertension havebeen equally distributed between thetwo groups. All the patients were usinga-adrenergic inhibitors for lower uri-nary tract symptoms and not hyperten-sion or any other medical indications.

Among the techniques recom-mended for IFIS, the usage ofmechanical devices increases operatingtime and atropine may be contraindi-cated in patients with cardiovascularproblems so the search for alternativeways of preventing IFIS is veryimportant. To our knowledge, it is thefirst study demonstrating the influenceof sub-Tenon lidocaine on IFIS.

The influence of the anaesthesiatype on the incidence and the severityof IFIS has not been studied in alarge multicentre trial of patients tak-ing oral tamsulosin. The choice of ananaesthetic, whether topical or regio-

nal injection, has been left entirely tothe surgeons discretion. It is thenimpossible to draw any conclusions,regarding the impact of the anaes-thetic technique on the pupil size andiris floppiness (Chang et al. 2007).

The main limitation of our study isthat we excluded the most severe casesof expected IFIS with preoperativepupillary diameter of £4 mm. Pupilsize has been shown to be inverselyrelated to the incidence and severityof IFIS (Casuccio et al. 2011), sothese patients had a high chance ofdeveloping IFIS. The choice of 4 mmas a cut-off point was a surgeons deci-sion and based on individual experi-ence. Patients with very small pupilwould most certainly require mechani-cal pupil dilating device, and the pri-mary indication to use the devicewould be pupil dilatation, not IFIS.Subsequent observation of the irisbehaviour would be impossible, andalso pupil size at the end of surgerywould not reflect any intra-operativeconstriction.

There always remains a subjectivityin the recognition and grading ofIFIS. We aimed to eliminate the inte-robserver variability by using the sameobserver and we blinded her to theresult of randomization. Difficultieswith ideal blinding of the study werecaused by minor complications ofsub-Tenon injection such as subcon-junctival leak, which might have beenvisible to the observer. Pupillary con-striction in millimetres was an objec-tive measure applied. Our study groupwas taking selective and nonselectivea-antagonists.

Our observation regarding the effec-tiveness of sub-Tenon 2% lidocaine inpreventing IFIS, has had a positiveimpact on our clinical practice of cata-ract surgery in patients remaining on a-antagonists. We believe using sub-Tenon injection of 2% lidocaine is avaluable alternative in dealing with pro-gressive pupillary constriction tomechanical pupil dilating devices. Thetechnique may also be employed by thesurgeons still on their learning curve.

Further research should addressclinical question of intra-operativeinjection of 2% lidocaine in cases withpreoperative very small pupil, andevaluate whether there is a beneficialeffect if it is combined with othertechnique so far recommended for themanagement of IFIS.

Acknowledgements

The authors have no financial interestin any methods or techniques used.The study was supported by theresearch grant from the Medical Uni-versity of Lodz.

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Received on August 20th, 2012.

Accepted on April 30th, 2013.

Correspondence:

Anna Klysik, MD, PhD, DRCOphth

Department of Ophthalmology

Medical University of Lodz_Zeromskiego 113

Lodz 90-549

Poland

Tel: + 48 608 653 720

Fax: + 48 42 639 36 34

Email: anna.klysik@umed.lodz.pl

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