Alpha antagonists and intraoperative floppy iris syndrome: A spectrum

Sharif A Issa, Omar H Hadid, Oliver Baylis, Margaret Dayan

Department of Ophthalmology, Royal Victoria Infirmary, Newcastle upon Tyne, UK

Background: To determine occurrence of features of intraoperative floppy iris syndrome (IFIS) during cataract surgery in patients taking systemic alpha-antagonists (AA).

Methods: We prospectively studied patients on AA and who underwent phacoemulsification. The following were recorded: pupil diameter preoperatively, iris flaccidity, iris prolapse and peroperative miosis.

Results: We studied 40 eyes of 31 subjects. Mean age was 78 years. Overall, 14 eyes (13 patients) showed signs of IFIS: 9/13 (69%) eyes of patients on tamsulosin, 1/18 (6%) eyes in the doxazosin group, 2/2 prazosin patients, 1/4 eyes in the indoramin group, and 1/2 eyes in two patients on a combination of doxazosin and tamsulosin. Most cases (92%) had only one or two signs of IFIS. Bilateral cataract surgery was undertaken in 9 patients but only one patient (on tamsulosin) had features of IFIS in both eyes, while 4 patients (2 on tamsulosin and 2 on other AA) showed signs of IFIS in one eye only, and 4 patients did not show IFIS in either eye.

Conclusion: Most AA were associated with IFIS, but it tends to present as a spectrum of signs rather than full triad originally described. Tamsulosin was most likely to be associated with IFIS; however, its intake does not necessarily mean that IFIS will occur. For patients on AA, the behavior of the iris intraoperatively in one eye is a poor predictor of the other eye. Surgeons should anticipate the occurrence of IFIS in any patient on AA.

Keywords: alpha blocker, alpha antagonist, cataract surgery, intraoperative floppy iris syndrome, tamsulosin.