I read the with interest the article by Vollman and associates, which reports a lot of important new data on intraoperative floppy iris syndrome (IFIS) incidence and complication rates. This is particularly important since the rate of IFIS complications is very controversial and the exact data on the type and prevalence of intraoperative complications is missing in available literature, as was shown in our paper. Moreover, the recent study by Chang and associates reported no complications in IFIS in both alpha-agonist and non-alpha-agonist patients.

The very original result of the study is the relatively high rate of IFIS occurrence in non-alpha-antagonist patients (24.8%), more than described in previous studies: from 0.61% to 12%–14%.

The authors, however, did not present the rate of complications in 3 IFIS subgroups: selective alpha blockers, nonselective alpha blockers, and non–alpha blockers. They pooled all IFIS complications into 1 category and compared it to non-IFIS complication rates. More data on nature and rate of specific complications in each of these subgroups would enable us to better understand the complication risks, especially in the non–alpha blockers group.

The authors also mentioned that pupillary expansion devices, such as the Malyugin ring, were shown to effectively manage IFIS. This is, however, a quite controversial issue. They referenced the study by Chang, in which 50% of the cases had iris prolapse in spite of Malyugin ring use. It is believed that pupil expansion devices dilate the pupil at the margin but do not stabilize the iris, especially at the midperiphery. On the other hand, several papers show the benefits of using iris retractors in IFIS, including diamond configuration or a single sub-incisional retractor, as they act as a physical barrier to the prolapsing iris.