We recently performed a large comparative retrospective case-control study evaluating the role of sex in intraoperative floppy-iris syndrome (IFIS). 1 In the study, we concluded that although much rarer, IFIS can appear in women and lead to a higher rate of complications and worse final visual outcomes than in men. As expected, the rate of IFIS in women was significantly lower than in men having cataract surgery (P!. 0001), with an incidence of 1.29%(25 of 1937 eyes) and 5.17%(97 of 1874 eyes), respectively. The most interesting finding in our study was that although the majority of IFIS cases in both sexes were, by coincidence, assigned to senior surgeons, the rate of posterior capsule rupture in women (28.00%) was much higher than in men (9.28%)(P Z. 02). Furthermore, the incidence of posterior capsule rupture and the final corrected distance visual acuity were significantly correlated with the severity grade of IFIS, but in women only (P!. 001 and P Z. 02, respectively).

It is known that a1 receptor inhibitors, which are widely used for benign prostate hyperplasia, are the most significant predisposing factors for the development of IFIS, with tamsulosin having the highest rates among these agents. 2, 3 Alpha-1 blockers are increasingly being prescribed to women as well for the management of bladder outlet obstruction and detrusor underactivity. However, in our study, which included 1678 female patients (1937 eyes), none of the 25 women who developed IFIS intraoperatively reported taking a1 blockers. The overall percentage of women on these agents was 0.42%(7 of 1678 patients). In contrast, more than 70% of men who developed IFIS were on systemic a1 blockers. 1 This finding motivated us to further investigate the possible causative factors for the development of IFIS, specifically in women. None of the preoperatively recorded ophthalmic pathologies, such as pseudoexfoliation syndrome, glaucoma, ocular hypertension, diabetic retinopathy, or patient age, were found to have an influence on the occurrence of IFIS in men or women (P O. 05). However, after thoroughly reviewing the full medical history and medication intake in IFIS cases in female patients, we realized that at the time of surgery, all 25 women who developed IFIS were taking angiotensin II receptor inhibitors for arterial hypertension (56%) or other reasons, such as heart failure (12%) and for the prevention of atrial fibrillation recurrence (16%) or renal failure (16%). Therefore, we performed a multivariate analysis including all systemic medications as possible risk factors for the occurrence of IFIS in women. When needed, patients were contacted again and asked to