Litigation Guides

Floppy Iris Syndrome Causes and Treatment Strategies

Intraoperative Floppy Iris Syndrome (IFIS) isn't just a medical complication; it can also raise legal concerns for both patients and surgeons. This article aims to equip attorneys with essential information about IFIS, its potential negligence claims, and key risk factors.

Medically Reviewed



Ophthalmological surgery is a delicate procedure to repair an incredibly fragile organ: the eye. Any surgical complications are extremely high risk given that a patient’s sight is on the line. Cataracts surgery is among the most routine eye procedures. However, it’s associated with a potential complication called intraoperative floppy iris syndrome (IFIS). IFIS is a type of small pupil syndrome, also known as miosis. This is categorized as excessive pupil constriction. Floppy iris syndrome also presents as a billowing iris and iris prolapse. IFIS during cataract surgery can potentially derail the procedure and lead to severe iris damage. For the best possible outcome, ophthalmologists must be aware of the patient’s medication history and be prepared for treatment tactics. These strategies include using iris hooks or retractors during surgery and administering Miochol postoperatively. For attorneys pursuing floppy iris syndrome-related injury cases, here’s what you need to know.


What is Intraoperative Floppy Iris Syndrome?

Intraoperative Floppy Iris Syndrome (IFIS), first identified by Chang et al. in a 2005 publication, is a condition that can occur during eye surgery. IFIS is known for causing complications in ophthalmological procedures and is characterized by three main features:

  1. Miosis: An abnormally constricted pupil hindering surgical procedures.
  2. Floppy Iris Behavior: The iris becomes unusually flexible and billows in response to standard irrigation and aspiration processes in the eye's anterior chamber.
  3. Iris Prolapse: There's a risk of the iris bulging or protruding into the incisions made for phacoemulsification (a technique used to remove cataracts with high-frequency ultrasound waves) and other surgical cuts, which can complicate the procedure.

Effectively managing IFIS often requires specialized tools like expansion rings and iris hooks. However, understanding the causes and potential complications is crucial for lawyers navigating potential negligence claims.


Intraoperative Floppy Iris Syndrome Causes

Use of Certain Medications

The primary cause of Intraoperative Floppy Iris Syndrome (IFIS) is the use of alpha-1 adrenergic receptor antagonists, most commonly tamsulosin (Flomax).

This medication is primarily used to treat urinary retention issues associated with benign prostatic hyperplasia (BPH) in men, though it may also be prescribed to women for urinary problems. Tamsulosin and similar drugs can affect the receptors controlling the iris's sphincter muscle contractions, leading to IFIS.

While tamsulosin is the most frequently implicated medication in this category, other drugs with similar mechanisms can also contribute to the occurrence of IFIS, including:

  • Terazosin (Hytrin) and alfuzosin (Uroxatral): These are other alpha-blockers also used to treat BPH.
  • Doxazosin (Cardura): This medication is used to treat high blood pressure and BPH.

Other Risk Factors

While medication is the key suspect, other factors can amplify the risk:

  • Age: As we age, our iris tissue naturally weakens, making it more susceptible to IFIS during surgery.
  • Previous eye surgery: A history of previous eye surgeries can elevate a patient's risk of experiencing IFIS.
  • Certain medical conditions: Diabetes, uveitis (eye inflammation), and nerve damage can affect the iris's ability to respond normally, increasing IFIS risk.
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Understand the surgical errors present in your IFIS case


Intraoperative Floppy Iris Syndrome Treatment

When ophthalmological surgeons encounter IFIS during a cataracts surgery, they have a few best practices for treatment. These include expansion rings and iris hooks/retractors. If used correctly, iris hooks offer a mechanical method for reversing miosis. Further, hooks and retractors can help prevent iris prolapse during surgery.


Floppy Iris Syndrome Post-Operative Care

Clinicians also have options to treat iris prolapse post-surgery. Most important for prolapse reversal is a watertight seal on the wound. Another crucial step is administering Miochol, a chemical solution that causes the pupil to contract.


Surgical Complications & Floppy Iris Syndrome

Surgeons must remain vigilant for signs of IFIS over the course of cataracts surgery. However, the tools and methods for treatment also present operational risks. Iris hooks and retractors can be effective interventions for IFIS. But they can also cause serious iris trauma (excessive stretching or manipulation) if implemented incorrectly.

Ophthalmological surgery presents a steep learning curve to clinicians. Attorneys pursuing IFIS cases should investigate operator error and training level when considering a surgical mismanagement approach.


Works Cited


Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg. 2005;31(4):664-673. doi:10.1016/j.jcrs.2005.02.027. URL


Chatziralli, I. P., Peponis, V., Parikakis, E., Maniatea, A., Patsea, E., Mitropoulos, P., & Medscape (2016). Risk factors for intraoperative floppy iris syndrome: a prospective study. Eye (London, England), 30(8), 1039–1044.

About the author

Wendy Ketner, M.D.

Wendy Ketner, M.D.

Dr. Wendy Ketner is a distinguished medical professional with a comprehensive background in surgery and medical research. Currently serving as the Senior Vice President of Medical Affairs at the Expert Institute, she plays a pivotal role in overseeing the organization's most important client relationships. Dr. Ketner's extensive surgical training was completed at Mount Sinai Beth Israel, where she gained hands-on experience in various general surgery procedures, including hernia repairs, cholecystectomies, appendectomies, mastectomies for breast cancer, breast reconstruction, surgical oncology, vascular surgery, and colorectal surgery. She also provided care in the surgical intensive care unit.

Her research interests have focused on post-mastectomy reconstruction and the surgical treatment of gastric cancer, including co-authoring a textbook chapter on the subject. Additionally, she has contributed to research on the percutaneous delivery of stem cells following myocardial infarction.

Dr. Ketner's educational background includes a Bachelor's degree from Yale University in Latin American Studies and a Doctor of Medicine (M.D.) from SUNY Downstate College of Medicine. Moreover, she is a member of the Board of Advisors for Opollo Technologies, a fintech healthcare AI company, contributing her medical expertise to enhance healthcare technology solutions. Her role at Expert Institute involves leveraging her medical knowledge to provide insights into legal cases, underscoring her unique blend of medical and legal acumen.

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