Sir,

We read with interest the paper by Gurbaxani and Packard1 on the use of intra-cameral phenylephrine to prevent floppy iris syndrome during cataract surgery. The authors acknowledge that there are limitations to the study but still claim that ‘all patients had a significant reduction in the signs of floppy iris syndrome’, whereas what they have demonstrated is that intra-cameral phenylephrine dilates the pupil. Whether this is in addition to the effect of pre-operative topical application of phenylephrine drops is not recorded.

The intra-operative floppy iris syndrome (IFIS) describes a spectrum of signs seen intraoperatively in patients on alpha-1a antagonists.2 This can range from a small pupil with rather poor iris tone to the full IFIS where the iris is billowing and prolapsing into and through all corneal incisions. There is no current evidence that IFIS will occur in everyone on tamsulosin, and a small pupil can be associated with other common conditions such as diabetes. IFIS has also been encountered in patients with no history of alpha-1a antagonist use (personal communication). It does not follow that a patient on tamsulosin with a small pupil is a certain candidate to develop IFIS, and therefore no treatment or manoeuvre can be confidently stated to prevent IFIS.

We would agree, however, that intra-cameral phenylephrine is a useful option in the management of IFIS, and thank the authors for bringing this technique to a wider audience. It should be considered as one of an array of available options for use sooner rather than later, if the surgeon is suspicious that IFIS may develop.