Severe IFIS less likely with alfuzosin

This prospective study found that both tamsulosin and alfuzosin significantly increase the risk of intraoperative floppy iris syndrome (IFIS), but tamsulosin was more likely to cause severe IFIS.

The authors compared IFIS rate and severity in 113 consecutive patients taking systemic tamsulosin or alfuzosin and scheduled for routine cataract surgery and 113 patients with no history of systemic α1-antagonists scheduled for routine cataract surgery. Two masked investigators reviewed video from all 226 surgeries and diagnosed the presence of IFIS and graded its severity.

They found that moderate to severe IFIS can occur in low-risk eyes when epinephrine is omitted from the irrigation bottle. Although both tamsulosin and alfuzosin significantly increased the risk of IFIS compared with patients without prior α1-antagonist intake, severe IFIS statistically was more likely with tamsulosin than with alfuzosin (P = 0.036). Severe IFIS was noted in 34.3 percent of tamsulosin eyes compared to 16.3 percent of alfuzosin eyes and 4.4 percent of control eyes. 

The authors write that the relatively high rate of IFIS in the control group was surprising. Although most of these were grade 1 cases (iris billowing only), 8 percent were grade 2 and 4.4 percent were grade 3. Similarly high rates of IFIS have not been reported previously in patients who had never taken systemic α1-antagonists. Since this study’s protocol did not allow epinephrine to be added to the irrigation bottle in an effort to avoid masking or preventing IFIS, they believe that this may explain this surprisingly high incidence.

They conclude that patients with symptomatic benign prostatic hyperplasia and cataracts needing a uroselective α1-antagonist may wish to try alfuzosin first. Also, α-agonists should be added to the irrigation bottle or injected directly intracamerally to reduce the rate of IFIS in all eyes.