In patients taking selective alpha-1a adrenergic antagonists for benign prostatic hyperplasia (BPH), the iris becomes increasingly unstable, a condition known as Intraoperative Floppy Iris Syndrome (IFIS). In these cases, the pupil often dilates poorly and asymmetrically and can even billow or constrict unexpectedly during the procedure, making the iris a particularly deceptive guide for centration. To ensure long-term stability, the capsulorhexis must be centered based on the Purkinje images or the anatomical center of the capsular bag, rather than the shifting pupillary margin. Using the limbus as your primary reference frame is essential. By ensuring the rhexis is circular and concentric with the limbal anatomy, the IOL optics remain aligned with the visual axis. Even with the asymmetric dilation or progressive miosis common in IFIS, a well-executed 5.0 to 5.5 mm capsulorhexis provides 360 degrees of anterior capsule overlap, which prevents asymmetric fibrosis and late-stage IOL tilt. This is a complete cataract case shown start to finish without editing to maximize complete learning.
