European Journal of Cardiovascular Medicine

Cataract, defined as opacity of the lens or its capsule, commonly occurs with increasing age and remains the leading cause of blindness globally. Major risk factor for cataract is age, Psuedoexfoliation syndrome is identified as a significant additional risk factor for the development of nuclear sclerosis.[1] The significant global burden of cataract blindness necessitates safe and effective surgical interventions to restore vision and improve quality of life. Pseudoexfoliation (PXF) syndrome is an age-related systemic microfibrillopathy caused by progressive deposition of greyish white fibrillar material over the anterior segment of the eye, particularly the anterior lens capsule, pupillary border, zonules, and ciliary body, as well as various other body tissues.[2] The prevalence of PXF was reported to be 6% with male preponderance in the rural population of south India. The major risk factor for PXF is increasing age, rarely occurring in individuals under 50 years. The global incidence of this disease varies widely, with a prevalence ranging between 1.5%and 40.9% worldwide. Certain geographic regions and ethnic groups are predisposedto the condition. PXF incidence varies between 3.6% and 34.2% in Europe, between1.5% and 22.1% in Asia, and between 1.5% and 40% in African countries, suggesting a general lack of consensus in these epidemiological studies. The highest incidence has been recorded in Scandinavia, where approximately half of open-angle glaucoma cases are attributed to pseudoexfoliation syndrome.[3] Gonioscopy shows pigmented trabecular meshwork, sometimes with a pigmented sampaolesi line anterior to schwalbes line. Trabecular meshwork shows dandruff like flakes and can get blocked by exfoliative material leading to secondary open angle glaucoma.[4] PXF is distinguished from true exfoliation, where heat or infrared radiation causes lens capsule damage. Pseudoexfoliation is identified as the most frequent cause of secondary glaucoma and risk of complications during cataract surgery.[5]  Pseudoexfoliation syndrome presents unique challenges during cataract surgery due to associated zonular instability and poor pupillary dilatation. The weakened zonules are prone to rupture during surgery, potentially resulting in vitreous loss, while rigid iris deposits prevent adequate pupillary dilatation, making surgical manipulation more difficult. Intraoperative complications include difficulty in nucleus delivery, iris prolapse, posterior capsular rent with or without vitreous loss, and zonular dialysis. Postoperative complications commonly include corneal edema, pigment dispersion on the intraocular lens, posterior capsular opacification, and optic capture. The factors affecting complications and visual outcomes include cataract maturity grade, zonular dehiscence, phacodonesis presence, pupillary dilatation adequacy, and raised intraocular pressure. Until recently, capsular and zonular weakness with reduced mydriasis due to PXF were considered poor indications for cataract surgery, although recent studies indicate successful outcomes, when necessary, precautions are taken.[6]

This descriptive longitudinal study was conducted at the Department of Ophthalmology, Department of Ophthalmology, Rama Medical College, Hospital & Research Centre, Hapur. The study was initiated after obtaining approval from the Institutional Ethics Committee, and all participants provided written informed consent in their vernacular language. The study included 60 patients aged 50 years and above with senile mature, hypermature, and immature cataracts associated with pseudoexfoliation syndrome. Patients with established glaucoma, traumatic or complicated cataracts, lens dislocation/subluxation, uncontrolled systemic diseases affecting visual outcomes, and corneal pathology unrelated to pseudoexfoliation syndrome were excluded from the study. Comprehensive preoperative evaluation was performed including visual acuity recording, retinoscopy, slit lamp examination before and after dilatation, keratometry, biometry, intraocular pressure measurements, gonioscopy, and IOL power calculation using SRK-2 formula. Fundus examination and lacrimal passage patency were assessed. Patients were categorized based on nuclear sclerosis grade, pupillary dilatation (adequate ≥6mm, inadequate <6mm), and presence or absence of phacodonesis. All patients underwent manual small incision cataract surgery under peribulbar block with posterior chamber intraocular lens implantation. Postoperative follow-up assessments were conducted on the 1st day, 2nd week, 4th week, and 6th week, including visual acuity testing, anterior segment examination, retinoscopy, and fundoscopy. Data was analyzed using Epi-info software with appropriate statistical tests including chi-square test and t-test, with significance set at P<0.05.

The study analyzed 60 eyes of patients with pseudoexfoliation syndrome who underwent manual small incision cataract surgery. Statistical analysis was performed using chi-square tests to determine associations between risk factors (pupillary dilatation, nuclear sclerosis grade, phacodonesis) and complications. Visual outcomes were assessed at multiple time points and correlated with preoperative factors. Results were considered statistically significant when P<0.05.

Table 1: Patient Demographics and Preoperative Characteristics

Table 3: Association of Pupillary Dilatation with Complications (P<0.05 significant)

Table 2: Intraoperative and Postoperative Complications

Table 4: Visual Outcomes and Surgical Results

The study findings demonstrate that pseudoexfoliation syndrome significantly impacts cataract surgery outcomes, with age and gender distribution consistent with previous literature. The majority of patients (46.66%) belonged to the 61-70 years age group, confirming that PXF increases with age, as shown in the Andhra Pradesh eye disease study [5] where prevalence was 6.29% in those ≥60 years. Male preponderance (53.34%) was observed, particularly in the 61-70 years group (67.85% males), which aligns with various studies suggesting increased outdoor UV exposure in males as a contributing factor. However, unilateral involvement (71.70%) was more common in our study, contrasting with other studies showing bilateral predominance. Regarding pupillary dilatation, 33.30% had poor dilatation (<6mm), consistent with study by Madhavi. [7] (35.5%). The predominance of lower nuclear sclerosis grades (NS1,2,3: 43.34%) differs from the Aravindstudy [8] but matches Sastry findings,[9] suggesting variable cataract progression patterns in PXF patients.  Intraoperative complications analysis revealed iris prolapse as the most common complication (33.3%), followed by corneal endothelial touch (25%) and zonular dialysis (21.7%). These findings correlated with that of study by Madhavi,[7] Sastry.[9] Higher nuclear sclerosis grades and presence of phacodonesis showed statistically significant correlations with increased complications. Postoperatively, iris pigment dispersion over IOL (66.7%), irregular pupil(optic capture) and corneal edema (60%) were most common, attributed to blood-aqueous barrier breakdown and inadequate pupillary dilatation during surgery. These findings are consistent with other studies by Naik [10] and Hemalatha.[11] The correlation between lens grade and complications, except for optic capture, remained statistically significant, emphasizing the importance of preoperative analysis of complications risk. Visual outcomes demonstrated that 50% of patients achieved good vision (6/6-6/12) at 6 weeks, with 36.67% belonging to lower nuclear sclerosis grades (NS1,2,3), indicating better outcomes with less mature cataracts. This finding supports the recommendation for earlier intervention in PXF patients before advanced cataract development. The successful PCIOL implantation rate of 90% despite the challenges posed by PXF syndrome indicates that with proper preoperative planning and surgical modifications, satisfactory visual outcomes can be achieved. Surgical techniques such as manual iris stretching, viscomydriasis, and sphincterotomy (performed in 25% of cases), use of capsular hooks and capsular tension hooks helps to manage poor pupillary dilatation. The study limitations include absence of a control group and focus on immediate complications only because patients from remote areas have difficulty with long-term follow-up.

This study demonstrates that pseudoexfoliation syndrome significantly increases the risk of intraoperative and postoperative complications during cataract surgery. Inadequate mydriasis and zonular weakness emerge as the primary risk factors, with poor pupillary dilatation (<6mm), higher grades of nuclear sclerosis, and presence of phacodonesis being significantly associated with increased complications. Despite these challenges, satisfactory visual outcomes can be achieved in 50% of patients, by adapting appropriate surgical techniques. The key to successful outcomes lies in meticulous preoperative assessment of risk factors, awareness of potential complications, and implementation of appropriate surgical modifications such as pupillary stretching techniques and sphincterotomy when indicated. Study of these risk factors helps surgeon in detailed counselling of the possible adverse outcome and the need to undergo surgery before it advances to high grade cataract. Also, it helps surgeon be prepared of the possible intraoperative challenges in these cases and thereby adapt appropriate surgical techniques to optimize visual outcome in pseudoexfoliation patients undergoing cataract surgery.

1. Ekström C, Botling Taube A. Pseudoexfoliation and cataract surgery: a population-based 30-year follow-up study. ActaOphthalmol.;93(8):774–777.

2. Plateroti P, Plateroti A, Abdolrahimzadeh S, Scuderi G. pseudoexfoliation syndrome and Pseudoexfoliation Glaucoma: A Review of the Literature with Updates on Surgical management. Journal of Ophthalmology. 2005; 1-9.

3. Tekin K, Inanc M, Elgin U.Monitoring and management of the patient with pseudoexfoliation syndrome: current perspectives. ClinOphthalmol. 1; 13:453-464.

4. Pranathi K, Magdum RM, Maheshgauri R, Patel K,Patra S. A study of complications during cataract surgery in patients withpseudoexfoliation syndrome. J ClinOphthalmol Res 2014; 2:7-11.

5. Fontana L, Coassin M, Iovieno A, Moramarco A, Cimino L. Cataract surgery in patients with pseudoex-foliation syndrome: current updates. ClinOphthalmol. 31; 11:1377-1383.

6. Ravi Thomas, Praveen Kumar Nirmalan, SannapaneniKrishnaiah;Pseudoexfoliation insouthernIndia:TheAndhraPradeshEyeDiseaseStudy. Invest. Ophthalmol. Vis. Sci. 2005; 46(4):1176.

7. Madhavi C, Latha y, Pyarakara D Kumar M. A study on the Visual Outcomes and Complications of Cataract Surgery in the Rural Population of Indian Patients with Pseudoexfoliation. Indian Journal of Clinical and Experiemental Ophthalmology. 2005; 1(3):168-174.

8. Haripriya A. The aravindpseudoexfoliation study: Surgical and first year postoperative resultsin eyes without phacodonesis and nonmiotic pupil. Ophthalmology. 2009;126 (3) :362–71.

9. Sastry P, Singal A .Cataract surgery outcome in patients with non-glaucomatous pseudo exfoliation. Romanian journal of ophthalmology. 61(3):196-201.

10. Naik AU, Gadewar SB. Visual Outcome of Phacoemulsification versus Small Incision Cataract Surgery in Pseudoexfoliation Syndrome – APilot Study. J ClinDiagn Res.;11(1):5–8.

11. Hemalatha BC, Shetty SB. Analysis of intraoperative andpostoperative complications  in pseudoexfoliation eyes undergoingcataract surgery. J ClinDiagn Res. 2006;10(4):NC05-8.