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Impact of intraoperative floppy IRIS syndrome in cataract surgery by phacoemulsification: Analysis of 622 cases
Impacto del síndrome de iris flácido intraoperatorio (IFIS) en cirugía de cataratas mediante facoemulsificación: análisis de 622 casos
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Herranz Cabarcos, R. Pifarré Benítez, A. Martínez Palmer" "autores" => array:3 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Herranz Cabarcos" "email" => array:2 [ 0 => "alejandra.herranz.cabarcos@gmail.com" 1 => "oftalmologia@csi.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "R." "apellidos" => "Pifarré Benítez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Martínez Palmer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Oftalmología, Consorci Sanitari Moisès Broogi, Sant Joan Despí, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Oftalmología, Hospital de l’Esperança, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Impacto del síndrome de iris flácido intraoperatorio (IFIS) en cirugía de cataratas mediante facoemulsificación: análisis de 622 casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1816 "Ancho" => 1558 "Tamanyo" => 79134 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Box plot scatter plot showing the duration of surgical time as a function of intraoperative observation of IFIS. 0: no IFIS; 1: IFIS.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Described by David Chang and John Campbell in 2005,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> intraoperative floppy iris syndrome (IFIS) is a complication of cataract surgery comprised within the narrow pupil syndromes and is characterised by the following triad: floppy iris with lack of tone, tendency to iridian prolapse and progressive intraoperative miosis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The development of this complication has been linked to treatment with alpha-adrenergic antagonists, mainly alpha-1-antagonists such as tamsulosin. Tamsulosin is the main therapeutic alternative for benign prostatic hyperplasia, which affects approximately 50% of men by the age of 60.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The development of IFIS in patients receiving these treatments is thought to be due to the presence of alpha-1 receptors in the dilator smooth muscle fibre of the iris.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Due to the long half-life of tamsulosin, a prolonged blockade of these receptors could produce a secondary atrophy of this muscle with a consequent decrease in iris stiffness during cataract surgery. Patients who have received or are receiving treatment with this drug have an odds ratio of 206.5 and a relative risk of 99.3 of developing IFIS compared to patients taking alpha-antagonists from any other family, according to the study published by Keklikci et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Of the patients treated with tamsulosin, 63–65% develop IFIS, however not all of this 63-65% develop IFIS with the same severity. About 17.5% have only sagging, another 17.5% also have a tendency to prolapse and 30% have the complete triad.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">From its initial description to the present day, the development of IFIS has been associated with male gender, older age, previous diagnosis of hypertension or treatment with finasteride, angiotensin II receptor inhibitors, benzodiazepines and antipsychotics.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The incidence of IFIS ranges from 2.2% of cataract surgeries, according to the series of 706 eyes published by Chang and Campbell<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> to 3.4% according to data published by Neff et al. whose series included 563 eyes.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Both series agree that the incidence of IFIS is 10 times higher in men than in women, which is consistent with the use of alpha-1-antagonists as the main treatment for benign prostatic hyperplasia. Female involvement is associated with the use of tamsulosin to relieve symptoms of uterine prolapse and, to a much lesser extent, other treatments such as angiotensin antagonists, antipsychotics or muscle relaxants.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Inadequate pupillary dilatation during cataract surgery can compromise surgical outcomes and lead to complications.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> For this reason, it is essential to detect patients at risk of IFIS preoperatively, asking the patient about treatments associated with an increased incidence (especially tamsulosin). Although the suspension of these treatments does not modify the risk of IFIS in the short-medium term, having this type of information allows us to optimise the planning of surgery.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Intraoperatively, the use of intracameral mydriatics, pupillary expanders (iris hooks or Malyugin ring) and a gentle and careful phacoemulsification technique are recommended, avoiding sudden pressure changes as much as possible.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The risk of intraoperative complications in patients with unplanned or improperly managed IFIS is 7-12% higher than in other patients.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> With proper intraoperative planning and management, the risk of complications in these patients is similar to that of other patients.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> However, we have not found any bibliography that analyses whether, beyond the risk of complications, these patients present other intraoperative differences with respect to patients who do not develop IFIS.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">Prospective observational case series study, carried out at the Hospital de l'Esperança - Parc de Salut Mar, Barcelona, Spain. This study was conducted in accordance with the Declaration of Helsinki. Consecutive patients referred for cataract surgery from the Specialised Care Centre who were between 18 and 99 years of age and who presented grade 2 or 3 cataract, according to the LOCS III classification, were included in the study. Patients with a history of diabetic retinopathy (DR) of any grade, atrophic or exudative age-related macular degeneration, uveitis, retinitis pigmentosa, retinal vascular obstructions or treatment with prostaglandin analogues that had not been discontinued one month prior to surgery were excluded.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The anamnesis questionnaire included information on gender, age, eye to be operated on as well as the presence of comorbidities such as diabetes mellitus or treatment of pathologies with alpha-agonists. In the case of diabetic patients, data were collected on the degree of metabolic control based on glycosylated hemoglobin (HbA1c).</p><p id="par0050" class="elsevierStylePara elsevierViewall">Cataract surgery was performed within 3 months of the initial visit.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Intraoperatively, all surgeries were performed by phacoemulsification using the Centurion (Alcon Laboratories, Switzerland) or Stellaris (Bausch + Lomb Laboratories, Laval, Canada) systems. As a general protocol of the Ophthalmology Department, in patients with a history of treatment with tamsulosin, it is generally decided to start the operation by administering diluted phenylephrine intrachamber.</p><p id="par0060" class="elsevierStylePara elsevierViewall">At the end of the operation, the surgeons were asked to complete a supplementary surgical sheet specifying the surgical time, the development of complications and the presence or absence of IFIS. If so, they were asked to indicate the degree of severity, based on the degrees of severity proposed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">For statistical analysis, continuous quantitative variables are described by means of mean and standard deviation (SD). Qualitative variables are described using frequency tables (number and percentage). For the comparison of continuous quantitative variables, the Student <span class="elsevierStyleItalic">t</span>-test was used. For qualitative variables, Fisher's exact test was used. Logistic regression models were constructed from the data collected. For the analysis of the correlation between IFIS diagnosis and risk of complications, the relative risk (RR) and odds ratio (OR) were calculated. Data analysis was performed using STATA 15.1 software (STATACorp LLC, Texas, USA).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">A total of 622 eyes of 502 patients were included. Of the included cases, 337 (62%) were female. The mean age of the sample was 74.8 years and 279 (51%) cases were left eyes. Of the patients included in the study, 99 had previously been diagnosed with diabetes mellitus. Of these, 4 had fair metabolic control (HbA1c 8.1-9.0) and 3 had problematic metabolic control (9.1-10.0). No patient had poor or very poor metabolic control with HbA1c above 10.1. Sixty-one cases of IFIS (11%) were observed, 13 of which were treated with tamsulosin and one with doxazosin. Twenty-three cases of IFIS were observed in female patients. The female:male ratio was approximately 1:3. The severity of the observed cases is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. 19 cases (3%) of severe IFIS were observed, of which 6 were treated with alpha-antagonists. In the present study, the relationship between IFIS and treatment with alpha-antagonists was not statistically significant applying Fisher's exact test, with a p-value > 0.1.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The mean operative time was 13.80 min (SD: 4.01 min) in patients without IFIS and 16.93 min (SD: 4.32 min) in patients with IFIS. The relationship between the duration of the surgical procedure in minutes and the presence of IFIS was statistically significant, applying a two-tailed or bilateral Student's <span class="elsevierStyleItalic">t</span>-test with a p-value of 0.01.</p><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> represents the relationship between the intraoperative diagnosis of IFIS and the duration of the surgical procedure. A higher average time is clearly observed in the group of patients in whom IFIS was observed, in addition to an overall lengthening of surgical times in these patients.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Intraoperative complications (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>) were observed in 17 eyes out of 17 patients (2.73%). The most frequently observed complication was posterior capsule rupture in 5 cases, followed by zonular alterations. One case of malignant or misdirectional glaucoma was also observed. Regarding the relationship between IFIS and complications, 5 patients of the 17 who presented with complications were diagnosed intraoperatively with IFIS. Of the 5 cases, 2 were considered by the surgeon as moderate (1 case of CPR, 1 case of persistent iris herniation). The remaining cases were classified as mild. The RR of complications in patients with IFIS is 2.71 (95%CI: 0.90-8.18, p = 0.07). The odds ratio of complications in patients with IFIS compared to patients without IFIS is 2.82 (95%CI: 0.88–9.01, p = 0.07).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The correlation between IFIS and the development of intraoperative complications has been reported in the literature since the description of this syndrome by Chang and Campbell. Specifically, if insufficient intraoperative planning measures are taken, the complication rate increases by 7-12% compared to patients without IFIS.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> With proper surgical planning, this risk was equal to that of patients without IFIS.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> The evidence subsequently published associating IFIS and surgical complications is very extensive and includes iridian trauma, increased postoperative IOP and posterior capsule rupture, among others.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> However, we have not found any published study that, like ours, associates the lengthening of surgical time in cases of any degree of IFIS with respect to patients without IFIS, regardless of surgical planning, i.e., despite the protocol application of diluted phenylephrine in patients treated with alpha-antagonists, those who developed IFIS did not present a higher rate of intraoperative complications but did present a lengthening of surgical time. Although this statistically significant lengthening of surgical time may seem clinically insignificant, it is noteworthy considering that cataract surgery is currently the most frequently performed outpatient procedure globally.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In relation to the distribution of cases of IFIS with respect to the gender of the patients who develop it, in our case a female:male ratio of 1:3 has been observed, when the usual ratio is 1:8 to 1:10.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> IFIS in female patients has been associated in the literature with a higher rate of surgical complications and with worse final visual acuity than in male patients. In turn, this has been associated with the fact that, in women, it is more difficult for the surgeon to foresee the presence of IFIS as it is much more infrequent, which has repercussions on the planning of cataract surgery.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> We believe that in our study the deviation of the rate of female versus male patients with IFIS with respect to the literature is because we did not include treatment with other drugs associated with IFIS, such as antihypertensives or antipsychotics, in the initial anamnesis.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Considering that, as mentioned above, cataract surgery is the most frequently performed outpatient surgical procedure globally,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and given the high level of evidence associating tamsulosin treatment with the risk of IFIS, it would be interesting to consider the use of more uroselective alpha-antagonists such as alfuzosin as a matter of course. However, the choice of treatment for benign prostate hyperplasia may be determined by other factors. To date, tamsulosin remains the treatment of choice in most cases as it has no effect on blood pressure and does not promote the development of orthostatic hypotension.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Therefore, in 2019 the American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS) issued a joint statement recommending either routine treatment of benign prostate hyperplasia with non-selective alpha-1 adrenergic receptor blockers or cataract surgery prior to initiating treatment with tamsulosin.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In conclusion, we believe that the fact that the diagnosis of IFIS systematically increases operative time in cataract surgery regardless of the degree of severity, together with the clear association between IFIS and tamsulosin, supports the preventive approach proposed by the AAO and the ASCRS.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">No conflicts of interests were declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1853072" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1610942" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1853071" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1610941" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-05-03" "fechaAceptado" => "2022-08-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1610942" "palabras" => array:5 [ 0 => "IFIS" 1 => "Tamsulosine" 2 => "Cataract" 3 => "Cataract surgery" 4 => "Surgical risk" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1610941" "palabras" => array:4 [ 0 => "IFIS" 1 => "Tamsulosina" 2 => "Cirugía de catarata" 3 => "Riesgo quirúrgico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Small pupil syndromes, including IFIS, increase the risk of complications during cataract surgery if proper surgical planning is not performed. Tamsulosin is associated with a very significant increase in the risk of IFIS, due to the prolonged inactivation of alpha-1 adrenergic receptors in the smooth muscle fiber of the iris.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Single-center prospective observational study, carried out at the Hospital de l'Esperança - Parc de Salut Mar.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">622 eyes of 502 patients were included, of which 337 (62%) were women. The mean age of the sample is 74.8 years. 61 cases of IFIS (11%) were observed, of which 13 received treatment with Tamsulosin and 1 with Doxazosin. 23 cases of IFIS were observed in female patients. The female:male ratio was approximately 1:3. 19 cases (3%) of severe IFIS were observed, of which 6 received treatment with alpha-antagonists, with no statistically significant correlation.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The mean surgical time was 13.80 min (Standard Deviation - SD: 4.01 min) in patients without IFIS and 16.93 min (SD: 4.32 min) in patients with IFIS. The relationship between the duration of the surgical procedure in minutes and the presence of IFIS was statistically significant, applying a 'two-tailed' or bilateral <span class="elsevierStyleItalic">t</span>-Student test with a p value of 0.01.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Regardless of the degree of severity, the diagnosis of IFIS lengthens the surgical time in cataract surgery. This represents yet another piece of evidence that supports the use of less selective alpha-1 adrenergic antagonist treatments than Tamsulosin or the performance of cataract surgery before starting these treatments.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Los síndromes de pupila estrecha, incluido el IFIS, aumentan el riesgo de complicaciones durante la cirugía de cataratas si no se realiza una correcta planificación quirúrgica. La Tamsulosina se asocia a un incremento muy significativo del riesgo de IFIS, debido a la inactivación prolongada de los receptores alfa-1 adrenérgicos en la fibra muscular lisa del iris.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo observacional unicéntrico, llevado a cabo en el Hospital de l’Esperança - Parc de Salut Mar.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 622 ojos de 502 pacientes, de los cuales 337 (62%) eran mujeres. La media de edad de la muestra es de 74.8 años. Se observaron 61 casos de IFIS (11%), de los cuales 13 recibían tratamiento con Tamsulosina y 1 con Doxazosina. Se observaron 23 casos de IFIS en pacientes mujeres. El ratio mujer: hombre fue de aproximadamente 1:3. Se observaron 19 casos (3%) de IFIS severo, de los cuales 6 recibían tratamiento con alfa-antagonistas, sin correlación estadísticamente significativa.</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">La media del tiempo quirúrgico fue de 13.80 min (Desviación Estándar - DE: 4.01 minutos) en pacientes sin IFIS y de 16.93 min (DE: 4.32 min) en pacientes con IFIS. La relación entre la duración del procedimiento quirúrgico en minutos y la presencia de IFIS fue estadísticamente significativa, aplicando un test t-Student ‘a dos colas’ o bilateral con un p valor de 0.01.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Independientemente del grado de severidad, el diagnóstico de IFIS alarga el tiempo quirúrgico en cirugía de cataratas. Esto supone otra evidencia más que apoya la utilización de tratamientos antagonistas adrenérgicos menos alfa-1 selectivos que la Tamsulosina o la realización de la cirugía de cataratas antes de iniciar dichos tratamientos.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1816 "Ancho" => 1558 "Tamanyo" => 79134 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Box plot scatter plot showing the duration of surgical time as a function of intraoperative observation of IFIS. 0: no IFIS; 1: IFIS.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IFIS severity grade</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Slight \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Good dilatation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Undulating movements of the iris without prolapse or constriction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate dilatation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Undulating movements of the iris with some pupil constriction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Poor dilatation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Undulating movements of the iris \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Iridian prolapse \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Progressive myosis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Degree of severity of IFIS.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IFIS diagnosis and degree of severity \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No IFIS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">484 (89%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mild IFIS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 (6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate IFIS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Severe IFIS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 (3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">IFIS diagnosis and degree of severity.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complication \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IFIS (n) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Associated with the IOL</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Toric rotation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>IOL refill \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">CPR</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Zonular lesions</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Seidel persistent</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Malignant glaucoma</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Angular bleeding</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Persistent herniation of the iris</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Intraoperative complications. Incidence of IFIS detected in patients with complications.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intraoperative floppy iris syndrome associated with tamsulosin" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.F. Chang" 1 => "J.R. Campbell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcrs.2005.02.027" "Revista" => array:6 [ "tituloSerie" => "J Cataract Refract Surg" "fecha" => "2005" "volumen" => "31" "paginaInicial" => "664" "paginaFinal" => "673" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15899440" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology of clinical benign prostatic hyperplasia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "K. Bin Lim" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ajur.2017.06.004" "Revista" => array:6 [ "tituloSerie" => "Asian J Urol" "fecha" => "2017" "volumen" => "4" "paginaInicial" => "148" "paginaFinal" => "151" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29264223" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Characterization of alpha(1)-adrenoceptor subtypes in the eye" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Wikberg-Matsson" 1 => "S. Uhlén" 2 => "J.E. Wikberg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1006/exer.1999.0753" "Revista" => array:6 [ "tituloSerie" => "Exp Eye Res" "fecha" => "2000" "volumen" => "70" "paginaInicial" => "51" "paginaFinal" => "60" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10644420" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence, clinical findings and management of intraoperative floppy iris syndrome associated with tamsulosin" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "U. Keklikci" 1 => "K. Isen" 2 => "K. Unlu" 3 => "Y. Celik" 4 => "M. Karahan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1755-3768.2008.01246.x" "Revista" => array:7 [ "tituloSerie" => "Acta Ophthalmol" "fecha" => "2009" "volumen" => "87" "paginaInicial" => "306" "paginaFinal" => "309" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18384448" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1353802020307331" "estado" => "S300" "issn" => "13538020" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Study Surgeon Group. Prospective masked comparison of intraoperative floppy iris syndrome severity with tamsulosin versus alfuzosin" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D.F. Chang" 1 => "J.R. Campbell" 2 => "J. Colin" 3 => "C. Schweitzer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ophtha.2013.10.031" "Revista" => array:6 [ "tituloSerie" => "Ophthalmology" "fecha" => "2014" "volumen" => "121" "paginaInicial" => "829" "paginaFinal" => "834" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24314842" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intraoperative floppy iris syndrome and its association with various concurrent medications, bulbus length, patient age and gender" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Wahl" 1 => "S.M. Tipotsch-Maca" 2 => "P.V. Vecsei-Marlovits" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00417-016-3515-7" "Revista" => array:6 [ "tituloSerie" => "Graefes Arch Clin Exp Ophthalmol" "fecha" => "2017" "volumen" => "255" "paginaInicial" => "113" "paginaFinal" => "118" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27761703" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intraoperative floppy iris syndrome: updated perspectives" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C.D. Christou" 1 => "I. Tsinopoulos" 2 => "N. Ziakas" 3 => "A. Tzamalis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2147/OPTH.S221094" "Revista" => array:6 [ "tituloSerie" => "Clin Ophthalmol" "fecha" => "2020" "volumen" => "14" "paginaInicial" => "463" "paginaFinal" => "471" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32109982" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Factors associated with intraoperative floppy iris syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K. Neff" 1 => "H.P. Sandoval" 2 => "L.E. Fernández deCastro" 3 => "A.S. Nowacki" 4 => "D.T. Vroman" 5 => "K. Solomon" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ophtha.2008.12.026" "Revista" => array:6 [ "tituloSerie" => "Ophthalmology" "fecha" => "2009" "volumen" => "116" "paginaInicial" => "658" "paginaFinal" => "663" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19243826" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Angiotensin receptor inhibitors as main predisposing factor for intraoperative floppy iris syndrome in women" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Tzamalis" 1 => "B. Malyugin" 2 => "N. Ziakas" 3 => "I. Tsinopoulos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcrs.2019.01.034" "Revista" => array:6 [ "tituloSerie" => "J Cataract Refract Surg" "fecha" => "2019" "volumen" => "45" "paginaInicial" => "696" "paginaFinal" => "697" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31030782" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Phacoemulsification techniques for patients with small pupils" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.D. Bartlett" 1 => "K.M. Miller" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Comp Ophthalmol Update" "fecha" => "2003" "volumen" => "4" "paginaInicial" => "171" "paginaFinal" => "176" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Phacoemulsification in eyes with a small pupil" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Vasavada" 1 => "R. Singh" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0886-3350(00)00361-8" "Revista" => array:7 [ "tituloSerie" => "J Cataract Refract Surg" "fecha" => "2000" "volumen" => "26" "paginaInicial" => "1210" "paginaFinal" => "1218" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11008050" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1552526018300724" "estado" => "S300" "issn" => "15525260" ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ponencia oficial Sociedad Española de Catarata: Cirugía del cristalino" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R. Lorente" 1 => "J. Mendicute" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2008" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prospective multicenter evaluation of cataract surgery in patients taking tamsulosin (Flomax)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D.F. Chang" 1 => "R.H. Osher" 2 => "L. Wang" 3 => "D.D. Koch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ophtha.2007.01.011" "Revista" => array:6 [ "tituloSerie" => "Ophthalmology" "fecha" => "2007" "volumen" => "114" "paginaInicial" => "957" "paginaFinal" => "964" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17467530" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global causes of blindness and distance vision impairment 1990–2020: a systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.R. Flaxman" 1 => "R.R.A. Bourne" 2 => "S. Resnikoff" 3 => "P. Ackland" 4 => "T. Braithwaite" 5 => "M.V. Cicinelli" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S2214-109X(17)30393-5" "Revista" => array:6 [ "tituloSerie" => "Lancet Glob Health" "fecha" => "2017" "volumen" => "5" "paginaInicial" => "e1221" "paginaFinal" => "e1234" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29032195" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The role of sex in intraoperative floppy-iris syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Tzamalis" 1 => "A. Matsou" 2 => "M. Dermenoudi" 3 => "P. Brazitikos" 4 => "I. Tsinopoulos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcrs.2018.08.029" "Revista" => array:6 [ "tituloSerie" => "J Cataract Refract Surg" "fecha" => "2019" "volumen" => "45" "paginaInicial" => "41" "paginaFinal" => "47" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30509747" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A comparison of varying α-blockers and other pharmacotherapy options for lower urinary tract symptoms" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C.R. Chapple" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Rev Urol" "fecha" => "2005" "volumen" => "7" "numero" => "Suppl 4" "paginaInicial" => "S22" "paginaFinal" => "S30" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16986051" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Intraoperative Floppy Iris Syndrome (IFIS) Associated with systemic alpha‐1 antagonists. ASCRS and AAO educational update statement. 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