Sir,

Intraoperative floppy iris syndrome (IFIS) is a recently described phenomenon affecting cataract surgery. It consists of poor preoperative pupil dilation together with progressive intraoperative pupil constriction, billowing of a flaccid iris stroma, and iris prolapse to the surgical incisions. IFIS has, to date, only been reported in patients symptomatic for benign prostatic hypertrophy (BPH) treated with tamsulosin, a subtype a1A-selective adrenergic receptor blocker.1 We present a case of typical IFIS occurring in a patient taking alfuzosin, a nonsubtype-selective a1-adrenergic receptor blocker.

Case report

An 85-year-old man presented with age-related cataract. He had no other ocular findings of significance. He had been treated for 3 years with alfuzosin for symptoms of BPH. He had never received any other a1-adrenergic receptor blockers. Small-incision phacoemulsification cataract surgery was planned. He was not asked to discontinue the alfuzosin before admission.

Preoperative pupil dilation was poor despite several instillations of cyclopentolate 1% and phenylephrine 2.5%. Lidocaine 2% (2 ml) was injected into the sub-Tenon's space inferonasally. A tunnelled temporal clear corneal incision was made. Iris behaviour typical of IFIS became apparent at hydrodissection. Disposable flexible translimbal iris retractors (Synergetics – Cat. No. Ref: 40.02) were therefore inserted in a diamond configuration similar to that described by Chang et al.1 Surgery was completed without further complications, with in-the-bag implantation of a flexible hydrophilic acrylic implant.

Comment

It has been postulated that a1A-subtype-selective adrenergic receptor antagonists cause IFIS by blocking the a1A-adrenergic receptors on the iris dilator muscle, resulting in disuse atrophy of the muscle; this in turn affects iris rigidity.1 Controversy exists over the receptor subtypes present in the prostate and the precise mechanism of action of this type of agents.2, 3, 4 Recent experience in our unit is in accord with Chang's report;1 the majority of patients treated with tamsulosin undergoing cataract surgery seem to display the features of IFIS. We have noted no benefit from the temporary cessation of treatment preoperatively.

The case we present here was, we believe, typical of IFIS. We are not aware of any previous reports of IFIS in patients treated with a1-adrenergic receptor blockers other than tamsulosin. It has been suggested that the a1A-subtype selectivity of tamsulosin might be accountable for the clinical manifestation of IFIS.1 Alfuzosin, although not a1A-subtype-selective in vitro,2, 3, 5, 6, 7, 8, 9 displays uroselective properties in vivo.5, 6, 7 We postulate that the overall in vivo affinity of the a1-adrenergic receptor blockers towards a1A-subtype receptors might be responsible for IFIS rather than the in vitro a1A-selectivity per se.2, 7

We agree with previous authors that preoperative recognition of patients at risk of IFIS allows for appropriate surgical planning in anticipation of IFIS, with the intention of reducing the risk of preoperative complications.1 It is our practice to insert, at commencement of surgery, disposable flexible translimbal iris retractors in a diamond configuration, as described by Oetting and Omphroy.10 This seems to allow the operation to be completed safely and with little added difficulty.

We believe that surgeons should anticipate IFIS in patients taking alfuzosin, in addition to those taking tamsulosin, and quite possibly in patients taking any of the uroselective a1-adrenergic receptor blockers. We are not aware of any reports of the nonuroselective a1-adrenergic receptor blockers causing IFIS.