Pseudoexfoliation syndrome (PXF) is an age-related condition in which abnormal fibrillar material accumulates in the eye ¹. For cataract surgeons, its importance is mechanical: PXF is strongly associated with zonular weakness and poor pupil dilation.
The zonules are tiny fibres that suspend the capsular bag like a trampoline. If they are weak, the bag becomes unstable during lens removal. Instability increases the likelihood of:
- Capsular stress and tearing
- Lens tilt or movement during phacoemulsification
- Vitreous prolapse if a tear occurs
Small pupils add difficulty: reduced visibility and tighter working space raise the risk of catching the capsule with instruments ².
PXF therefore increases PCR risk not because the capsule is “thin”, but because the whole capsular-bag support system is less stable ¹.
Management strategies include:
- Use of pupil expansion devices when needed
- Capsular tension rings for zonular weakness
- Lower-stress phaco techniques and careful nucleus management
With appropriate planning, excellent outcomes are routine ³, but patients with PXF should be counselled that surgery is more complex and may require additional stabilising devices.
References
- Shingleton BJ, Crandall AS, Ahmed IIK. Pseudoexfoliation and the cataract surgeon: preoperative, intraoperative, and postoperative issues. J Cataract Refract Surg. 2009;35(6):1101-1120.
- Drolsum L, Haaskjold E, Davanger M. Pseudoexfoliation syndrome and cataract surgery: a prospective study. Acta Ophthalmol Scand. 1998;76(3):337-341.
- Vazquez-Ferreiro P, Carrera-Hueso FJ, Fikri-Benbrahim N, et al. Complications of cataract surgery in pseudoexfoliation syndrome: a systematic review and meta-analysis. Int Ophthalmol. 2019;39(10):2481-2492.
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- Why does pseudoexfoliation increase the risk of PCR?
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