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.
References
Chang DF, Campbell JR . Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005; 31(4): 664–673.
Kenny BA, Miller AM, Williamson IJ, O'Connell J, Chalmers DH, Naylor AM . Evaluation of the pharmacological selectivity profile of alpha 1 adrenoceptor antagonists at prostatic alpha 1 adrenoceptors: binding, functional and in vivo studies. Br J Pharmacol 1996; 118(4): 871–878.
Michel MC, Grubbel B, Taguchi K, Verfurth F, Otto T, Kropfl D . Drugs for treatment of benign prostatic hyperplasia: affinity comparison at cloned alpha 1-adrenoceptor subtypes and in human prostate. J Auton Pharmacol 1996; 16(1): 21–28.
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Lowe FC . Role of the newer alpha, -adrenergic-receptor antagonists in the treatment of benign prostatic hyperplasia-related lower urinary tract symptoms. Clin Ther 2004; 26(11): 1701–1713.
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Martin DJ . Preclinical pharmacology of alpha1-adrenoceptor antagonists. Eur Urol 1999; 36(Suppl 1): 35–41 (discussion 65).
Buzelin JM, Fonteyne E, Kontturi M, Witjes WP, Khan A . Comparison of tamsulosin with alfuzosin in the treatment of patients with lower urinary tract symptoms suggestive of bladder outlet obstruction (symptomatic benign prostatic hyperplasia). The European Tamsulosin Study Group. Br J Urol 1997; 80(4): 597–605.
Martin DJ, Lluel P, Guillot E, Coste A, Jammes D, Angel I . Comparative alpha-1 adrenoceptor subtype selectivity and functional uroselectivity of alpha-1 adrenoceptor antagonists. J Pharmacol Exp Ther 1997; 282(1): 228–235.
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Settas, G., Fitt, A. Intraoperative floppy iris syndrome in a patient taking alfuzosin for benign prostatic hypertrophy. Eye 20, 1431–1432 (2006). https://doi.org/10.1038/sj.eye.6702291
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DOI: https://doi.org/10.1038/sj.eye.6702291
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