Theodossiadis and associates investigated the use of a recent technology to perform quantitative assessment of the pupil dynamics in patients receiving systemic treatment with α ₁ -adrenergic receptor antagonists. They suggested that preoperative identification of the eyes likely to demonstrate intraoperative floppy iris syndrome (IFIS) should be performed, because it allows “the surgeon to plan and prepare for a more complicated procedure and find potential solution in a timely manner to prevent any postoperative visual disturbances.” In fact, they added that “IFIS might increase the risk of vision-threatening complications.”

We respectfully highlight that patients receiving α ₁ -blockers are a tiny percentage, representing 2% of the cataract population. If it is true that with aging of the male population the incidence of benign prostatic hyperplasia increases, the awareness regarding the possibility of IFIS during cataract surgery has been raised over the past few years among physicians, who are encouraged to use the systemic drugs that are less likely induce IFIS, such as alfuzosin. Current good medical practice recommends that cataract surgery in all the patients with history of α ₁ -blockers treatment should be assigned to expert surgeons who master all the complimentary strategies shown to be effective in minimizing the risk of intraoperative complications related to IFIS. These include appropriate wound construction, use of intracameral adrenergic drugs, mechanical pupillary dilation, appropriate ophthalmic viscosurgical device, and low-motion phacoemulsification. In fact, in a multicenter prospective study involving senior cataract surgeons using some of the above-named strategies, Chang and associates observed that 95% of the treated eyes achieved a final corrected distance visual acuity of 20/40 or better, with a posterior capsule rupture rate of 0.6% (1/167; 95% confidence interval, 0% to 1.8%), which compares well with the posterior capsule rupture rates described in large epidemiologic studies.

In light of our considerations, we doubt the clinical relevance of the research conducted by the authors, and we would like to challenge them to agree that no detrimental effect on the patient would be generated when the correct techniques and appropriate surgeons are involved. We believe this is an important point from a medicolegal perspective.

Finally, 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 would not be a cost-effective procedure.