Sir,

Intraoperative floppy iris syndrome (IFIS) was first described by Chang and Campbell1 as a triad of a flaccid iris stroma that undulates and billows in response to intraocular fluid currents, a propensity for the floppy iris stroma to prolapse toward the incisions despite proper wound construction, and progressive intraoperative pupil constriction. The Food and Drug Administration warned health professionals about this side effect observed during cataract surgery in some patients currently or previously treated with tamsulosin,2 an α2-adrenergic-receptor antagonist licensed for the functional symptoms of benign prostatic hyperplasia (BPH).

The awareness of this problem is evidenced by the surge in the publications on this topic since.3, 4, 5 The reported prevalence of this condition is 63–100% among tamsulosin users.1, 3 More recent anecdotal reports6 have suggested that it may be associated with all four commercially available α1-adrenergic-receptor antagonists (alfuzosin, doxazosin, tamsulosin, and terazosin). We here report the first case of IFIS in a patient on doxazosin.

Case report

Since January 2006, we have routinely started to identify the use of tamsulosin in patients who are listed for cataract surgery. An audit of 577 eyes that underwent phacoemulsification with intraocular lens implant between January and April 2006 revealed seven patients (10 eyes) who were on tamsulosin. All the patients were male with a mean age of 77.8 years. In this retrospective audit, there was no concern reported with pupillary dilation preoperatively. IFIS of any degree was seen in seven eyes (70%). Modification of the surgical technique, that is, use of iris hooks, was needed in three eyes and corneal or side port incision needed suturing in four eyes. All the patients achieved good visual acuity and no complications were reported.

Additionally, we identified two patients who were taking nonselective α-blockers for benign prostatic hyperplasia. One of these patient on doxazosin (2 mg twice a day) showed typical features of IFIS including intraoperative miosis and iris prolapse through the main and side port. Although the surgery was completed without resorting to any additional manoeuvres, iris chafing was noted at the end of surgery. This patient was in good general health and did not have past history of any ocular disease. The patient achieved best-corrected visual acuity of 6/6. The other patient on alfuzosin (2.5 mg twice a day) underwent routine surgery and did not reveal any features suggestive of IFIS.

Discussion

Doxazosin is a nonselective α-blocker that is used for BPH and as a combination treatment for hypertension. Published medical literature suggests the possibility of IFIS in patients on other α-blockers; however, it has not been reported so far.

Since the identification of this case, we have started to identify the use of all the α-blockers in patients booked for cataract surgery. As there are no preoperative variables to suggest the possibility of this unexpected and unpredictable syndrome, we believe that identification of these cases preoperatively is the best safe-guard.

This case highlights that a careful medical history should be taken for every patient undergoing cataract surgery to elucidate IFIS predisposition based on concurrent α-blocker use.