Intraoperative floppy iris syndrome (IFIS) is a cataract surgery complication that remains a challenge for eye surgeons. It is caused by the antagonism of alfa-1-adrenergic receptors within the dilator muscle of the iris, thus preventing the iris from dilation during a cataract surgery. The long-term blocking alfa-1 adrenergic receptors by the chronic use of a number of systemic medications may lead to permanent anatomical atrophy of the dilator muscle of the iris. The most common drugs associated with the development of IFIS are tamsulosin and other alpha-1 adrenergic receptor antagonists prescribed to patients with low urinary tract symptoms (LUTS). There are other systemic medications that have been reported to have increased risk for IFIS. It is crucial for the ophthalmologist to identify the high-risk patients prone to develop IFIS. Its presence may complicate the course of cataract surgery, ultimately negatively affecting visual outcome. Cataract surgery should be performed by an experienced eye surgeon using alternative pharmacological and surgical techniques. Interdisciplinary cooperation is essential to mitigate potential complications. Patients should be informed by their physicians about the need to report a medication history to their eye specialists, especially before cataract surgery.

Department of Ophthalmology Faculty of Medicine and Dentistry Palacky University Olomouc Czech Republic

Department of Ophthalmology University Hospital Olomouc Czech Republic

Department of Urology Faculty of Medicine and Dentistry Palacky University Olomouc Czech Republic

Department of Urology University Hospital Olomouc Czech Republic

Zobrazit více v PubMed

Heissigerová J, Bydžovský J, Diblík P, Dubská Z, Fichtl M, Glezgová J, Huňa L, Kalvodová B, Klímová A, Kousal B, Kuthan P, Lišková P, Michalčíková M, Novák P, Rezková L, Růžičková E, Skalická P, Sklenka P, Svozílková P. Nemoci čočky. In: Pátková V, Špičková M, editors. Oftalmologie. pro pregraduální i postgraduální přípravu. Praha: Maxdorf 2018. p.149-158. (In Czech)

Lunacek A, Mohamad Al-Ali B, Radmayr C, Weber M, Horninger W, Findl O, Plas E. Ten years of intraoperative floppy iris syndrome in the era of α-blockers. Cent Eur J Urol 2018;71:98-104. PubMed DOI

Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005;31:664-63. PubMed DOI

Yang X, Liu Z, Fan Z, Grzybowski A, Wang N. A narrative review of intraoperative floppy iris syndrome: an update 2020. Ann Transl Med 2020;8:1546. PubMed DOI

Christou CD, Tsinopoulos I, Ziakas N, Tzamalis A. Intraoperative Floppy Iris Syndrome: Updated Perspectives. Clin Ophthalmol 2020;14:463-71. PubMed DOI

Chang DF, Campbell JR, Colin J, Schweitzer C; Study Surgeon Group. Prospective masked comparison of intraoperative floppy iris syndrome severity with tamsulosin versus alfuzosin. Ophthalmology 2014;121:829-34. PubMed DOI

Santaella RM, Destafeno JJ, Stinnett SS, Proia AD, Chang DF, Kim T. The effect of α1-adrenergic receptor antagonist tamsulosin (Flomax) on iris dilator smooth muscle anatomy. Ophthalmology 2010;117:1743-49. PubMed DOI

Ozcura F, Gultekin Irgat S. Bilateral Intraoperative Floppy Iris Syndrome Associated with Silodosin Intake. Eurasian J Med 2020;52:100-2. PubMed DOI

Shah N, Tendulkar M, Brown R. Should we anticipate intraoperative floppy iris syndrome (IFIS) even with very short history of tamsulosin? Eye 2009;23:740. PubMed DOI

Goseki T, Ishikawa H, Ogasawara S, Mashimo K, Nemoto N, Taguchi Y, Yago K, Shimizu K. Effects of tamsulosin and silodosin on isolated albino and pigmented rabbit iris dilators:possible mechanism of intraoperative floppy-iris syndrome. J Cataract Refract Surg 2012;38:1643-9. PubMed DOI

Chang DF, Osher RH, Wang L, Koch DD. Prospective multicenter evaluation of cataract surgery in patients taking tamsulosin (Flomax). Ophthalmology 2007;114:957-64. PubMed DOI

Nguyen DQ, Sebastian RT, Kyle G. Surgeon's experiences of the intraoperative floppy iris syndrome in the United Kingdom. Eye (Lond) 2007;21:443-4. PubMed DOI

Storr-Paulsen A, Jørgensen JS, Norregaard JC, Thulesen J. Corneal endothelial cell changes after cataract surgery in patients on systemic sympathetic α-1a antagonist medication (tamsulosin). Acta Ophthalmol 2014;92:359-63. PubMed DOI

Enright JM, Karacal H, Tsai LM. Floppy iris syndrome and cataract surgery. Curr Opin Ophthalmol 2017;28:29-34. PubMed DOI

Chatziralli IP, Peponis V, Parikakis E, Maniatea A, Patsea E, Mitropoulos P; Medscape. Risk factors for intraoperative floppy iris syndrome: a prospective study. Eye (Lond) 2016;30:1039-44. PubMed DOI

Storr-Paulsen A. Management of Intraocular Floppy Iris Syndrome (IFIS) in Cataract Surgery. In: Zaidi F, editor. Cataract Surgery. London: IntechOpen 2013. p.143-148. DOI

Keklikci U, Isen K, Unlu K, Celik Y, Karahan M. Incidence, clinical findings and management of intraoperative floppy iris syndrome associated with tamsulosin. Acta Ophthalmol 2009;87:306-9. PubMed DOI

Lorente R, de Rojas V, Vázquez de Parga P, Moreno C, Varela J, Landaluce ML, Méndez J, Lorente B. Intracameral phenylephrine 1.5% for prophylaxis against intraoperative floppy iris syndrome: prospective, randomized fellow eye study. Ophthalmology 2012;119:2053-8. PubMed DOI

Bendel RE, Phillips MB. Preoperative use of atropine to prevent intraoperative floppy-iris syndrome in patients taking tamsulosin. J Cataract Refract Surg 2006;32:1603-5. PubMed DOI

Arshinoff SA. Dispersive-cohesive viscoelastic soft shell technique. J Cataract Refract Surg 1999;25:167-73. PubMed DOI

Arshinoff SA. Modified SST-USST for tamsulosin-associated intraoperative [corrected] floppy-iris syndrome. J Cataract Refract Surg 2006;32:559-61. PubMed DOI

Klečka J, Hora M. Benigní hyperplazie prostaty a současné trendy v léčbě. Urologie pro Praxi 2007;3:120-26. (In Czech)

Slíva J, Votava M. Léčiva používaná v porodnictví a urologii. In: Blahoš J, editor. Farmakologie. Praha: Triton 2011. p. 320-321. (In Czech)

Kaczmarek IA, Prost ME, Wasyluk J. Clinical risk factors associated with intraoperative floppy iris syndrome: a prospective study. Int Ophthalmol 2019;39:541-49. PubMed DOI

Zhang HL, Huang ZG, Qiu Y, Cheng X, Zou XQ, Liu TT. Tamsulosin for treatment of lower urinary tract symptoms in women: a systematic review and meta-analysis. Int J Impot Res 2017;29:148-56. PubMed DOI

Pourmand A, Nadendla R, Mazer-Amirshahi M, O'Connell F. Tamsulosin for urolithiasis: a review of the recent literature and current controversies. Am J Emerg Med 2016;34:2217-21. PubMed DOI

Leibovici D, Bar-Kana Y, Zadok D, Lindner A. Association between tamsulosin and intraoperative "floppy-iris" syndrome. Isr Med Assoc J 2009;11:45-9. PubMed

Popescu RM, Ober C, Sevastre B, Taulescu M, Negru M, Melega I, Bogdan S, Nicula C, Coman I. Complications of cataract surgery in Wistar rats undergoing treatment with tamsulosin. Exp Ther Med 2019;17:137-46. PubMed DOI

Shtein RM, Hussain MT, Cooney TM, Elner VM, Hood CT. Effect of tamsulosin on iris vasculature and morphology. J Cataract Refract Surg 2014;40:793-8. PubMed DOI

Chatterjee S, Agrawal D. Silodosin-associated intraoperative floppy iris syndrome. Indian J Ophthalmol 2017;65:538-9. PubMed DOI

Ipekci T, Akin Y, Hoscan B, Tunckiran A. Intraoperative floppy iris syndrome associated with silodosin. Acta Ophthalmol 2015;93(4):e306. doi: 10.1111/aos.12549 PubMed DOI

Christou CD, Kourouklidou M, Mataftsi A, Oustoglou E, Ziakas N, Tzamalis A. Silodosin as a predisposing factor of intraoperative floppy iris syndrome (IFIS): an observational propensity score-matching cohort study. Int Ophthalmol 2022;42:393-99. PubMed DOI

Karaca U, Kaya E, Ayyildiz O, Ozge G, Kucukevcilioglu M, Usta G, Mutlu FM. Evaluation of static and dynamic Pupillometry changes in men using Silodosin for benign prostatic hypertrophy. BMC Ophthalmol 2021;21:125. PubMed DOI

Hara N, Mizusawa T, Obara K, Takahashi K. The role of naftopidil in the management of benign prostatic hyperplasia. Ther Adv Urol 2013;5:111-9. PubMed DOI

Oshika T, Ohashi Y, Inamura M, Ohki K, Okamoto S, Koyama T, Sakabe I, Takahashi K, Fujita Y, Miyoshi T, Yasuma T. Incidence of intraoperative floppy iris syndrome in patients on either systemic or topical alpha(1)-adrenoceptor antagonist. Am J Ophthalmol 2007;143:150-1. PubMed DOI

Blouin MC, Blouin J, Perreault S, Lapointe A, Dragomir A. Intraoperative floppy-iris syndrome associated with alpha1-adrenoreceptors: comparison of tamsulosin and alfuzosin. J Cataract Refract Surg 2007;33:1227-34. PubMed DOI

Venkatesh R, Veena K, Gupta S, Ravindran RD. Intraoperative floppy iris syndrome associated with terazosin. Indian J Ophthalmol 2007;55:395-96. PubMed DOI

Haridas A, Syrimi M, Al-Ahmar B, Hingorani M. Intraoperative floppy iris syndrome (IFIS) in patients receiving tamsulosin or doxazosin-a UK-based comparison of incidence and complication rates. Graefes Arch Clin Exp Ophthalmol 2013;251:1541-5. PubMed DOI

Zaman F, Bach C, Junaid I, Papatsoris AG, Pati J, Masood J, Buchholz N. The floppy iris syndrome - what urologists and ophthalmologists need to know. Curr Urol 2012;6:1-7. PubMed DOI

Naslund MJ, Miner M. A review of the clinical efficacy and safety of 5alpha-reductase inhibitors for the enlarged prostate. Clin Ther 2007;29:17-25. PubMed DOI

Issa SA, Dagres E. Intraoperative floppy-iris syndrome and finasteride intake. J Cataract Refract Surg 2007;33:2142-43. PubMed DOI

Wong AC, Mak ST. Finasteride-associated cataract and intraoperative floppy-iris syndrome. J Cataract Refract Surg 2011;37:1351-4. PubMed DOI

Horvath K, Vultur F, Simon V, Voidazan S, Mühlfay G. Research on intraoperative iris behavior in rabbits treated with tamsulosin and finasteride. Hippokratia 2015;19:20-4. PubMed

Chatziralli IP, Sergentanis TN, Papazisis L, Moschos MM. Risk factors for intraoperative floppy iris syndrome: a retrospective study. Acta Ophthalmol 2012;90:e152-e153. PubMed DOI

Dreikorn K. Complementary and alternative medicine in urology. BJU Int 2005;96:1177-84. PubMed DOI

Neff KD, Sandoval HP, Fernández de Castro LE, Nowacki AS, Vroman DT, Solomon KD. Factors associated with intraoperative floppy iris syndrome. Ophthalmology 2009;116:658-63. PubMed DOI

Tsatsos M, MacGregor C, Athanasiadis I, Moschos M, Mataftsi A, Ziakas N. Phytotherapy and intraoperative floppy iris syndrome: the implications. Eye 2017;31:823-26. PubMed DOI

Slíva J, Votava M. Antipsychotika. In: Blahoš J, editor. Farmakologie. Praha: Triton 2011. p. 248-250. (In Czech)

Unal M, Yücel I, Tenlik A. Intraoperative floppy-iris syndrome associated with chronic use of chlorpromazine. Eye 2007;21:1241-42. PubMed DOI

Pringle E, Packard R. Antipsychotic agent as an etiologic agent of IFIS. J Cataract Refract Surg 2005;31:2240-41. PubMed DOI

Bilgin B, Ilhan D, Çetinkaya A, Ünal M. Intraoperative floppy iris syndrome associated with quetiapine. Eye 2013;27:673. PubMed DOI

Ford RL, Sallam A, Towler HM. Intraoperative floppy iris syndrome associated with risperidone intake. Eur J Ophthalmol 2011;21:210-11. PubMed DOI

Matsuo M, Sano I, Ikeda Y, Fujihara E, Tanito M. Intraoperative floppy-iris syndrome associated with use of antipsychotic drugs. Can J Ophthalmol 2016;51:294-96. PubMed DOI

Zarbin MA, Anholt RR. Benzodiazepine receptors in the eye. Invest Ophthalmol Vis Sci 1991;32:2579-87. PubMed

Altiaylik Ozer P, Altiparmak UE, Unlu N, Hazirolan DO, Kasim R, Duman S. Intraoperative floppy-iris syndrome: comparison of tamsulosin and drugs other than alpha antagonists. Curr Eye Res 2013;38:480-6. PubMed DOI

Papadopoulos R, Bachariou A. Intraoperative floppy-iris syndrome associated with chronic intake of donepezil. J Cataract Refract Surg 2007;33:1997-98. PubMed DOI

González-Martín-Moro J, González-López JJ, Zarallo-Gallardo J, Fernández-Miguel Y. Intraoperative floppy iris syndrome after treatment with duloxetine: coincidence, association, or causality? Arch Soc Esp Oftalmol 2015;90:94-96. PubMed DOI

Ugarte M, Leong T, Rassam S, Kon CH. Intraoperative floppy-iris syndrome, alpha1-adrenergic antagonists, and chronic intake of mianserin: is there an association? J Cataract Refract Surg 2007;33:170. PubMed DOI

Gupta A, Srinivasan R. Floppy iris syndrome with oral imipramine: a case series. Indian J Ophthalmol 2012;60:136-38. PubMed DOI

Fine IH, Dworetzky J, Hoffman RS, Packer M. Range of drugs associated with IFIS. J Cataract Refract Surg 2009;35:202. PubMed DOI

Calotti F, Steen D. Labetalol causing intraoperative floppy-iris syndrome. J Cataract Refract Surg 2007;33:170-1. PubMed DOI

Chatziralli IP, Sergentanis TN. Risk factors for intraoperative floppy iris syndrome: a meta-analysis. Ophthalmology 2011;118:730-35. PubMed DOI

Altan-Yaycioglu R, Gedik S, Pelit A, Akova YA, Akman A. Clinical factors associated with floppy iris signs: a prospective study from two centers: Ophthalmic Surg Lases Imaging 2009;40:232-38. PubMed DOI

Tint NL, Dhillon AS, Alexander P. Management of intraoperative iris prolapse: stepwise practical approach. J Cataract Refract Surg 2012;38:1845-52. PubMed DOI

Cheung CM, Awan MA, Saudramouli S. Prevalence and clinical findings of tamsulosin-associated intraoperative floppy-iris syndrome. J Cataract Refract Surg 2006;32:1336-9. PubMed DOI