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We thank Carifi and Theoulakis for commenting on our article. However, we contend that our research and proposed pupil dynamics assessment can have a clinical impact, especially from medicolegal and ethical perspectives.


First, Carifi and Theoulakis mention that patients taking α 1 -blockers represented only 2% of the cataract population, based on a study published in 2005. However, benign prostatic hyperplasia is a common clinical condition among the elderly male population, occurring in 50% to 70% of men older than 60 years and in 80% to 90% of those aged older than 80 years, which is similar to the prevalence of cataract. We respectfully highlight that because the prevalences of both benign prostatic hyperplasia and cataract increase with age, a rising number of cataract patients treated with an adrenergic α 1 -blocker should be expected. Therefore, a sizeable proportion of patients may experience intraoperative floppy iris syndrome (IFIS). Additionally, although there has been increased awareness of IFIS among physicians and in the urological literature over the past few years, a recent study showed that most urologists (91%) prefer to prescribe tamsulosin for benign prostatic hyperplasia, although most of them know that IFIS is associated with poor dilation during cataract surgery (81% of urologists) and specifically with tamsulosin (53% of urologists).


On warning regarding the risk of IFIS for patients taking α 1 -blockers and undergoing cataract surgery, assignment of such patients to senior surgeons with all the complimentary strategies has been shown to be effective in reducing the risk of intraoperative complications related to IFIS and in achieving a good final visual acuity, as shown by Chang and associates in a sample of 167 eyes. However, Bell and associates recently published the first population-based cohort study to evaluate the association between tamsulosin and serious adverse events after cataract surgery in a sample of more then 96 000 patients. They found that those treated with tamsulosin had a 2.3 times risk of serious ophthalmic postoperative adverse events, and the estimated number needed to harm was 255, which is a potentially clinically important effect. It is also of note that, according to the 2008 special report of the American Society of Cataract and Refractive Surgery Cataract Clinical Committee on Clinical Experience with IFIS, most members of the American Society of Cataract and Refractive Surgery commonly reported iris trauma and posterior capsule rupture as complications of IFIS, with 52% and 23% of respondents, respectively, reporting these complications at a higher rate than in non-IFIS eyes. Interestingly, if they themselves had mildly symptomatic cataracts, 64% of respondents would avoid taking tamsulosin or would have their cataract removed first, which highlights their concern regardless of all the available complimentary surgical strategies available today and also highlights the need for a method to identify the tendency for IFIS before cataract surgery.


Last, the comment that “given that the suggested pupil measurements should be performed 3 times, 10 minutes apart, and with the same lighting conditions, this assessment would be a time-consuming and a not cost-effective procedure” is in fact not the case. In our study, we performed the pupil measurements 3 times, similar to other studies of the pupil, to confirm the accuracy of sequential measurements and to guarantee the reliability of our measurements and the correct design of our study. However, in the published article, we present 2 measurements, before and after dilation, which are of clinical importance. The measurement from the flash emission until the calculations to appear on the device lasts for 4 seconds, and we suggest only 2 measurements, before and after dilation. We believe that we present a rapid and cost-effective method, given the importance of information provided to the surgeon before surgery.


The authors’ comments are not concentrated on the real meaning of the study. They instead prefer to propose ways applied by expert surgeons to minimize the risk of intraoperative complications related to IFIS. It has to be noted, however, that all ophthalmic surgeons who perform cataract surgery are not experts, and therefore unexpected complications can be minimized or avoided by the proper knowledge related to IFIS.

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Jan 12, 2017 | Posted by in OPHTHALMOLOGY | Comments Off on Reply
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