Sir,

Intraoperative floppy-iris syndrome (IFIS) during phacoemulsification has been described in patients who are using α1-adrenoceptor (AR)-blocking agents such as tamsulosin, terazosin, alfuzosin, and doxazosin.1 Recently, labetolol and mianserin which are antihypertensive and antidepressant agents, respectively have also been reported to be associated with this syndrome.2, 3 We report a new case in which IFIS developed in a patient owing to chronic use of chlorpromazine.

A 48-year-old man with schizophrenia had bilateral nuclear cataract. Despite standard pharmacologic dilation (topical cyclopentolate 1%, tropicamide 1%, phenylephrine 10%) for fundus examination, the patient's pupils did not dilate well. He had no posterior synechia, pseudoexfoliation, history of miotic use, or diabetes mellitus. His medical history revealed that he has been using chlorpromazine 50–200 mg (average 100 mg) for 29 years for schizophrenia.

Right cataract operation was planned under general anaesthesia. A relatively small capsulorhexis was performed. During the phacoemulsification procedure, characteristics of IFIS developed: there was a flaccid iris stroma, which undulated, billowed, and prolapsed to the main and side incisions, and progressive miosis occurred. Miosis did not respond to intracameral adrenaline irrigation. Although we performed nucleus emulsification successfully, posterior capsule rupture developed during cortical cleaning. Vitreous loss was not present. A foldable intraocular lens was implanted into the sulcus.

Despite well-documented adverse effects, and the advent of a new generation antipsychotic drugs, chlorpromazine remains one of the most commonly used and inexpensive treatments for people with schizophrenia.4 It has antagonistic effects on α1ARs, serotonin 5-HT2 receptors, and dopamine D1 and D2 receptors. Its α1AR-blocking activity is very prominent, and is responsible for some of the side effects including orthostatic hypotension, high-resting pulse rates, and impotence.5

We believe that the most likely cause for IFIS in this patient was chronic chlorpromazine use. α1ARs predominate in sympathetically mediated iris dilator muscle contraction resulting in mydriasis. Long-term blockade of these receptors by chlorpromazine may prevent mydriasis and result in dilator muscle tone loss. We are not sure whether the occurrence of IFIS would be prevented or not if chlorpromazine had been stopped before surgery. Disuse atrophy may have developed in this patient because of long-term use of an α1AR antagonist. Anyway, we suggest that discontinuation of chlorpromazine might be a wise course of action before cataract surgery to avoid the possibility of IFIS.