Intraoperative Floppy Iris Syndrome: Severity Profile, Anaesthetic Management, Medication Association – A Single-Surgeon Cohort

To analyse the severity profile of intraoperative floppy iris syndrome (IFIS), the anaesthetic approach used for its management, and the prevalence of  medication use.

II Ophthalmology Department, Aristotle University of Thessaloniki

Single Surgeon Tertiary Referral Centre

All consecutive cataract surgeries complicated by IFIS were prospectively recorded over the study period. IFIS was graded intraoperatively (Stage 0-III based on iris billowing, miosis, and prolapse). Data collected included patient sex, systemic medications (i.e specifically α1-blockers, antihypertensives, herbal agents), and anaesthetic technique (topical or sub-Tenon’s). Descriptive statistical analysis was performed on severity distribution, anaesthetic strategy, medication profile, and gender differences. Literature review contextualised findings against reported IFIS risks and demographics.

Seventy-six IFIS cases were analysed. Stage I, II, and III accounted for 32.9%, 30.3%, and 34.2% respectively, with stage II–III representing 64.5%. Sub-Tenon’s anaesthesia was used in 88% of cases, while topical alone was used in 5.3%. 40.5% of male  patients had concurrent or prior use of 5a reductase inhibitors with 5a reductase inhibitors. Shorter mean Axial Length 22.79 mm vs. 23.59 mm was seen in males (p=0.0015). There was a p=0.03 Gender difference in severe IFIS and a p=0.005 α1-Blocker association with severe IFIS. Notably, 65.8% had no history of α1-blocker use. Female patients comprised 38.2% of the cohort. Herbal medication use was identified in 6.6% overall and 17.2% of females with herbal-associated IFIS occurring in females.

IFIS frequently occurs without α1-blocker exposure (65.8% in this series, higher than many reports dominated by tamsulosin users) and is not predominantly male in contemporary practice, with females representing nearly 40% of cases. The high utilisation of sub-Tenon’s anaesthesia underscores its value in managing moderate-to-severe IFIS. Herbal medications, particularly in female patients, represent an under-recognised risk factor likely via α-adrenergic effects, highlighting the need for comprehensive preoperative screening including herbals and gender-specific risks (e.g., ARBs, other agents). These findings support tailored surgical strategies and detailed history-taking to reduce unanticipated complications.