A 67-year-old man was referred for cataract surgery. He had noticed deteriorating vision in the left eye, greater than the right, over the last eight months with difficulty driving due to glare. He had a history of essential hypertension controlled by perindopril and had been taking tamsulosin for three years for benign prostatic hypertrophy with some symptomatic relief.
On examination, best-corrected visual acuity was 6/12 in the right and 6/24 in the left eye. Both pupils dilated minimally with topical tropicamide 1%, but light responses were normal. Apart from nuclear sclerotic cataracts, the rest of the anterior and posterior segment examination including intraocular pressures was normal.
Cataract surgery to the left eye was performed under local anaesthesia. Despite routine preoperative dilation with topical tropicamide 1%, cyclopentolate 1% and phenylephrine 2.5%, the patient's pupil remained miosed at 3 mm in diameter. This did not improve with instillation of topical phenylephrine 10%. Further intervention only increased the pupillary diameter to 3.5 mm.
The iris was noted to be atonic and had a propensity to prolapse out of the main clear corneal incision. A diagnosis of intraoperative floppy iris syndrome was suspected. Routine cataract surgery could not proceed with such a small pupil size. Four iris retracting hooks were needed to stretch the pupil to over 6 mm to enable the cataract to be removed (Fig. 1). Postoperatively, the patient's best-corrected visual acuity in his left eye improved to 6/12 on day one and 6/6 at four weeks.
Fig. 1 Iris retracting hooks used to stretch the pupil during cataract surgery
As cataracts and the use of alpha1 adrenergic antagonists increase with age, it is not surprising that the incidence of intraoperative floppy iris syndrome has been reported to occur in up to 3.7% of cataract surgeries.2 It is important that patients due for cataract surgery are told to remind their ophthalmologist if they have ever taken tamsulosin. The ophthalmologist should also seek this history. Preoperative cessation of the drug is not currently recommended. With recognition of the potential problem and careful pre-and intraoperative planning, theophthalmologist can minimise surgical complications associated with intraoperative floppy iris syndrome.
- Chang DF, Osher RH, Wang L, Koch DD. Prospective multi center evaluation of cataract surgery in patients taking tamsulosin (Flomax). Ophthalmol 2007;114:957-64.
- Neff KD, Sandoval HP, Fernandez de Castro LE, Nowacki AS, Vroman DT, Solomon KD. Factors associated with intraoperative floppy iris syndrome. Ophthalmol 2009;116:658-63.
- Bell CM, Hatch WV, Fischer HD, Cernat G, Paterson JM, Grunier A, et al. Association between tamsulosin and serious ophthalmic adverse events in older men following cataract surgery. JAMA 2009;301:1991-6.