Intraoperative floppy iris syndrome (IFIS)

Intraoperative floppy iris syndrome (IFIS) was first described by Chang and Campbell in 2005

• defined by flaccid iris stroma resulting in fluttering and billowing of the iris, tendency of iris prolapse through the surgical incisions and progressive intraoperative pupil constriction
  • IFIS can be characterized as complete, when all the three features are present or incomplete, when even one feature is missing
    
  • IFIS may lead to complications, such as posterior capsular rupture, loss of vitreous, iris prolapse, iris stroma atrophy, capsulorhexis tear, and anterior chamber hemorrhage, due to restricted surgical field secondary to miosis
    
    
• there is a reported association between IFIS and taking alpha blockers, which are commonly used for the treatment of benign prostatic hyperplasia
  • IFIS has been associated with use of tamsulosin, doxazosin, terazosin; also with labetalol (a selective alpha and beta blocker)
  • study evidence suggests risk of IFIS is highest with use of tamsulosin of all the alpha blockers
  • there are case reports of other associations with development of IFIS including use of antipsychotics, losartan and metformin
• systemic factors that have been implicated for IFIS predisposition include diabetes and hypertension

A study noted (5):

• alpha-1 blockers, tricyclic antidepressants, atypical antipsychotics, carbonic anhydrase inhibitors, corticosteroids, 5-alpha reductase inhibitors, beta-blockers, prostaglandin analogs, and beta-2 agonists were linked to cases of IFIS
• imipramine demonstrated the highest disproportionate association with the incidence of IFIS (reporting odds ratio [ROR], 251.66), followed by tamsulosin, an alpha-1 blocker (ROR, 171.44), and chlorpromazine, an atypical antipsychotic (ROR, 91.30; P < .0001 for all)
• use of brinzolamide, a carbonic anhydrase inhibitor (ROR, 409.63), and salbutamol, a beta-2 agonist (ROR, 67.12; P < .0001 for both), was disproportionately associated with the incidence of IFIS among women but not among men

Consider intracameral phenylephrine to increase pupil size in people at risk of floppy iris syndrome (4).

Reference:

1. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005; 31: 664-673.
2. 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: 480-486.
3. Schwinn DA, Afshari NA. alpha (1)-adrenergic receptor antagonists and the iris: New mechanistic insights into floppy iris syndrome. Surv Ophthalmol. 2006;51:501-12.
4. NICE (October 2017). Cataracts in adults: managementacts in adults: management
5. Lakhani, Moiz et al.Drugs Associated With Floppy Iris Syndrome: A Real-World Population-Based Study. AJO 2025; 275: 36 - 46.