Let’s talk about floppy iris syndrome. That’s right, in a specialty with complicated words like “phthisis” and “glaucomflecken,” we have a thing called floppy iris syndrome.

It’s time for the ophthalmology/urology crossover you never thought you needed and probably still don’t.

Alpha 1 blockers like tamsulosin relax smooth muscle in the urinary system. Unfortunately, they also relax the iris dilator muscle, despite repeated requests by ophthalmologists that they please not do that

As a result, the pupil fails to dilate and becomes a giant pain in the ass during cataract surgery. In this video, you can see the iris constantly moving in and out. This slightly increases the risk for complications like iris injury, hyphema, and posterior capsule rupture.

Since floppy iris syndrome was described in 2005, we have developed techniques to perform these surgeries safely, but ophthalmologists still groan when we see a patient on flomax (not unlike the groan heard from men with BPH when they try to urinate)

Tamsulosin is the worst offender, likely because it’s a selective alpha 1 blocker with an insanely long half life. The non-selectives (doxazosin, prazosin, terazosin) are much less associated with floppy iris. So how does this affect you, the non-ophtho who prescribes BPH meds?

Well in a perfect world, anybody over 60 who needs tamsulosin would get an eye exam to see if they need cataract surgery. That way we could do the surgery first, then let the patient live out their days eating fistfuls of flomax and peeing freely

But that’s not reasonable and mostly unnecessary considering we are now well equipped to handle these types of surgical cases. Anybody who has spent any time doing cataract surgery at the VA is unphased by the floppiest of irises

There’s also no evidence to suggest stopping alpha blockers prior to surgery will decrease iris floppiness, so keep prescribing tamsulosin if needed, the increased QOL for patients with BPH certainly outweighs the slight inconvenience I experience as a cataract surgeon