We greatly appreciate the interest of Dr Grzybowski in our study and are happy to address his comments below.

Our study reports the prevalence of intraoperative floppy iris syndrome (IFIS) and the use or not of alpha-antagonist in the Veterans’ Health Administration population as recorded by the Ophthalmic Surgery Outcomes Database. Given the methodology of the study, estimation of incidence rates is not possible. We reported the prevalence of medication use in our population, which is very particular. As mentioned in our study, a limitation of the Ophthalmic Surgery Outcomes Database is the potential selection bias inherent in patients who receive care at the Veterans Health Administration, since the population is predominantly male and male patients use alpha-antagonists at a much higher rate than female patients.

We refer Dr Grzybowski to Table 2 in our study, which did demonstrate the complication rates between patients taking selective alpha-antagonists, nonselective alpha-antagonists, and no medication that experienced IFIS.

We mentioned that other studies have shown effective management of IFIS with pupillary expansion rings. However, regarding our study, we reported what we observed: a more frequent use of devices in patients with selective alpha-antagonists. We did not address the effectiveness on the management of IFIS and could not make recommendations on this based upon these findings. We agree with Dr Grzybowski that more evidence-based medicine reports and scientific evidence are needed to assess the management of IFIS.