The Intraoperative Floppy Iris Syndrome

A t the annual meeting of the ASCRS in April, John R. Campbell, MD, and I reported on two companion studies that we conducted to examine the incidence, characteristics, surgical outcomes, and etiology of floppy irides during cataract surgery.1,2 We named this condition the intraoperative floppy iris syndrome (IFIS) (Figures 1 to 3). Based upon retrospective observations by Dr. Campbell regarding a possible association with tamsulosin (Flomax; Boehringer-Ingelheim Pharmaceuticals, Inc., Ridgefield, CT), we attempted to evaluate IFIS with both a retrospective and a prospective study. Because there is no mention of any such syndrome in the literature, we were not even sure how to define it at first. In a prospective study of 900 consecutive cases in which I as the surgeon was masked as to the patient’s medication history, approximately 2% of the eyes (21/900) and 2% of the total patients (16/741) were deemed to have a floppy iris. Fifteen of these 16 patients were either taking Flomax or had taken the agent in the past. This systemic alpha-1 antagonist drug is the most commonly prescribed medication for benign prostatic hypertrophy. None of the 725 non-IFIS patients was taking Flomax. The retrospective study evaluated every cataract surgery performed in a two-surgeon (Dr. Campbell’s) practice during the prior calendar year (2003). A floppy iris was noted in the operative report in approximately 2% of the total eyes (16/706) and patients (10/511). Every one of the IFIS patients was taking Flomax. Six patients on Flomax therapy did not have a floppy iris noted in the operative report. An additional 1.5% (11/706) of the patients were taking other systemic alpha-blockers (Hytrin [Abbott Laboratories Inc., North Chicago, IL], Cardura [Pfizer Inc., New York, NY], or Minipress [Pfizer Inc.]). None of these patients demonstrated a floppy iris. The rate of IFIS in the two combined studies—totaling more than 1,600 eyes and 1,250 patients—was 2%. Our findings convey the importance of ophthalmologists’ recognizing and learning how to manage IFIS.