We read with interest the findings of Dhingra et al.1 Further reports on the problems of intraoperative floppy-iris syndrome (IFIS), associated with doxazosin have been described. The most recent (n=31) finding is that 37% of patients taking doxazosin had features of IFIS.2 However, larger series indicate that the problem is uncommon and less severe than for the α1A-antagonist tamsulosin.3, 4, 5 An observational study by Cheung et al3 of 1689 patients undergoing cataract surgery found that 9 out of 42 patients using doxazosin had incomplete IFIS. Nguyen et al4 found that out of 375 patients with IFIS taking an α1-antagonist, six were using doxazosin. This was also reflected by the experience of Chadha et al5 who found that 1 patient out of 48 using doxazosin developed incomplete IFIS.
However, we also recently encountered two patients using doxazosin with resultant moderate IFIS during cataract surgery. The first patient was a 76-year-old Caucasian male using 8 mg doxazosin po od for hypertension. The second was a 72-year-old Asian male taking 4 mg of doxazosin po od for benign prostatic hypertrophy. In both cases, there was incomplete pupil dilatation (5 mm for first patient and 6 mm for the second) and iris undulation was noted after initial wound construction. We successfully utilised dilute intracameral phenylephrine (as described by Gurbaxani and Packard6) to prevent iris prolapse and maintain pupil size during phacoemulsification. Surgery was completed successfully without complication.
Both patients were noted to be taking an α1-antagonist preoperatively and the possibility of IFIS was anticipated. Undoubtedly, this influenced the decision to utilise intracameral phenylephrine early as a means of preventing intraoperative complications. Atthough our subjective grading of moderate IFIS (like Dhingra et al1) appears more severe than the experience of larger series, we agree that the possibility of well-described intraoperative complications should be anticipated. Among the numerous management options available, we found that the use of intracameral phenylephrine offered a quick and effective method for preventing further problems.
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Cheung CMG, Awan MA, Peh KK, Sandramouli S . Incidence of intraoperative floppy-iris syndrome in patients on either systemic or topical α1-adrenoreceptor antagonist. Am J Ophthalmol 2007; 143 (6): 1070.
Nguyen D, Sebastien RT, Kyle G . Surgeon's experience of the intraoperative floppy iris syndrome in the United Kingdom. Eye 2007; 21 (3): 443–444.
Chadha V, Borooah S, Tey A, Style C, Singh J . Floppy iris behaviour during cataract surgery: associations and variations. Br J Ophthalmol 2007; 91: 40–42.
Gurbaxani A, Packard R . Intracameral phenylephrine to prevent floppy iris syndrome during cataract surgery in patients on tamsulosin. Eye 2007; 21 (3): 331–332.
There are no proprietary interests to declare.
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Williams, G., Tsaloumas, M. The use of intracameral phenylephrine in the management of intraoperative floppy-iris syndrome with doxazosin. Eye 22, 1094 (2008). https://doi.org/10.1038/sj.eye.6703084
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