Pseudoexfoliation Syndrome (PEX) is an age-related systemic disorder most commonly observed in individuals over 60 years of age. It is characterized by the abnormal production and deposition of fibrillar extracellular material on ocular tissues, including the anterior lens capsule, iris, zonules, corneal endothelium, and angle structures [1,2]. The hallmark sign is a "target-like" pattern on the anterior lens capsule, best visualized after pupillary dilation [3]. PEX is the most frequent identifiable cause of secondary open-angle glaucoma, often progressing to severe, medically unresponsive glaucoma requiring surgical intervention [4,5].

PEX eyes are associated with poor pupillary dilation, iris transillumination defects, zonular weakness, and increased risk of complications during cataract surgery, such as lens subluxation and corneal decompensation [3,6]. The corneal endothelium shows reduced cell density and pleomorphism, increasing the risk of decompensation even with moderate intraocular pressure elevation postoperatively [7]. PEX may initially present unilaterally, but becomes bilateral in approximately 50% of cases over 20 years [2]. Additionally, systemic associations include hypertension, coronary artery disease, peripheral vascular disease, and sensorineural hearing loss [8,9].

Given its ocular and systemic implications, comprehensive ophthalmic evaluation and monitoring for glaucoma are essential in all patients with PEX [4,5].

Study Design and Setting

A cross-sectional observational hospital-based study was conducted at the Department of Ophthalmology, Amaltas Institute of Medical Sciences, Dewas, Madhya Pradesh, from April 2023 to September 2024.

Study Population

Fifty-eight patients with pre-senile or senile cataract and pseudoexfoliation syndrome were included.

Inclusion and Exclusion Criteria

Inclusion: Cataract patients with pseudoexfoliation in one or both eyes.

Exclusion: Patients with glaucoma, increased IOP, prior trauma, intraocular surgeries, lens subluxation conditions, uveitis, and posterior segment pathology.

Study Methods

Verbal consent was obtained. Data collection included demographics and history.

Clinical Examination

Examinations involved visual acuity, refraction, external eye check, slit-lamp biomicroscopy for pseudoexfoliation, corneal changes, anterior chamber depth, phacodonesis, lens subluxation, pupillary response, and cataract type.

Preoperative Assessment

Patients underwent assessment of AC angle by Van Herick’s method, gonioscopy, IOP measurement, fundus exam, keratometry, A-scan, lacrimal patency test, RBS, ECG, and fitness evaluations for diabetics, hypertensives, and cardiac patients.

Preoperative Care

TT injection, lignocaine test dose, and pupil dilation with tropicamide and phenylephrine were administered. NSAIDs were used to prevent intraoperative miosis.

Surgical Procedure

Under peribulbar anesthesia, a sclero-corneal tunnel was made, capsulorrhexis performed, nucleus and cortex removed, and IOL implanted if possible. Anterior vitrectomy was done if needed.

Postoperative Care

Vision, IOP, and slit-lamp exams were done. Patients received topical and systemic antibiotics and steroids with regular follow-ups.

Table 1 shows the distribution of patients by age group. Most patients were in the 61–70 years age group (43.10%), followed by those aged 71–80 years (31.03%). The least number of patients were in the 81–90 years age group (6.90%). The youngest group, aged 51–60 years, made up 18.97% of the total.

The gender distribution of the study population. There were more male patients (58.62%) than female patients (41.38%).

Diagram depicts the residential background of the patients. A majority of the patients (62.07%) were from rural areas, while 37.93% were from urban areas.

Table 2 illustrates the socioeconomic status of the patients based on the modified Kuppuswamy classification. Most patients belonged to the upper middle class (31.03%), followed by the upper lower class (24.14%). An equal number of patients (22.41% each) were from the lower and lower middle classes.

Table 3 shows the laterality of eye involvement. Most patients (75.86%) had bilateral pseudoexfoliation, while 24.14% had unilateral involvement.

Table 4 illustrates the distribution of preoperative best corrected visual acuity (BCVA). The most common visual acuity was 5/60, seen in 25.86% of patients. Other common values included 4/60 (13.79%) and 2FFC (8.62%). A small number of patients had better vision, such as 6/60 (6.90%) and 6/36 (1.72%). Several patients had poor vision like hand movements (5.17%) and counting fingers close to face (5.17%).

Table 5 highlights the presence of systemic comorbidities. Hypertension was the most common comorbidity, seen in 20.69% of patients. Diabetes mellitus and ischaemic heart disease were present in 6.90% of patients each.

Table 6 depicts the iris findings on examination. All patients (100%) had a normal iris pattern. Pseudoexfoliation material on the pupillary margin was observed in 96.55% of cases. Iris atrophy was present in 22.41%, posterior synechiae in 18.97%, and iridodonesis in 10.3% of patients.

Figure shows the findings related to pupil size and reaction before dilatation. Most patients (86.21%) had a pupil size of 3.5mm, while 13.79% had a smaller pupil size of 3 mm. Regarding pupil reaction, 87.93% of eyes reacted normally to light, whereas 12.07% showed sluggish reaction

Figure highlights the pupil size and reaction after dilatation. The most common pupil size was 5 mm (39.66%), followed by 6 mm (13.79%) and 8 mm (22.41%). A few patients had smaller dilated pupils measuring 4 mm (17.24%) or 7 mm (6.90)

Table 7: illustrates the preoperative intraocular pressure (IOP). All patients (100%) had normal IOP before surgery. None of the patients had raised IOP. The mean IOP was 16.7 mmHg, with a standard deviation of 1.1 mmHg. The range was between 13 mmHg and 19 mmHg

Figure illustrates the examination findings of the lens. Pseudoexfoliation material on the lens surface was present in 93.1% of patients. Lens subluxation or dislocation was observed in 8.6% of cases. Phacodonesis was noted in 3.4% of patients.

Figure shows the types of cataract found in patients with pseudoexfoliation. The most common type was nuclear sclerosis grade III , seen in 37.93% of patients. nuclear sclerosis grade II (NSIII) were each seen in 22.41% of cases. Nuclear sclerosis grade IV (NSIV) was observed in 25.86% of patients , MC seen in 15.55% of pts. and HMSC, were seen in smaller numbers ranging from 8.62%

Figure depicts the gonioscopy findings. Zonular dialysis seen in 8.62% patients, and in the PEX material deposit in trabecular meshwork in 60.3%. Open angles were present in all patients (100%).

Figure highlights the intraoperative complications observed during surgery. The most common complication was sphincterotomy, performed in 34.5% of cases. Difficulty during anterior capsulotomy was reported in 19% of patients. Zonular dialysis and posterior capsular rent were each seen in 15.5% of cases. Vitreous loss was also noted in 15.5% of patients. Other complications included phacodonesis-related issues (12.1%), difficulty during nucleus delivery (10.3%), and corneal descement membrane peel(6.9%).

Figure shows the postoperative complications. Inflammation was the most frequent, seen in 19% of patients. Raised intraocular pressure occurred in 17.24% of cases. Corneal oedema was noted in 15.5% of patients.  while 12.1% had postoperative pigment dispersion.

Table 8 illustrates the surgical outcomes in terms of the type of IOL implanted. Most patients (93.2%) received a posterior chamber intraocular lens (PCIOL). Aphakia was observed in 6.8% of patients.

Table 9 depicts the uncorrected visual acuity (BCVA) after surgery. The most common postoperative visual acuity was 6/9, seen in 37.93% of patients, followed by 6/12 in 29.31% and 6/18 in 20.69%. One patient had 6/24 vision (1.72%). Poorer visual acuities such as counting fingers close to face (CFCF) and 1FTFC were each seen in 3.45% of patient

This hospital-based observational study was conducted over 18 months at Amaltas Institute of Medical Sciences, Dewas, to assess intraoperative complications, preoperative findings, and postoperative outcomes in 58 patients with pseudoexfoliation (PXF) undergoing manual small incision cataract surgery (MSICS). Most patients were aged 61–70 years (43.10%), male (58.62%), and from rural areas (62.07%). Bilateral PXF was present in 75.86%. Hypertension was the most common comorbidity (20.69%).

Preoperatively, 96.55% showed PXF on the pupillary margin, with 22.41% having iris atrophy. Most pupils measured 3.5 mm pre-dilation, with sluggish reaction in 12.07%. Post-dilation, the commonest pupil size was 5 mm (39.66%). All patients had normal intraocular pressure. Nuclear sclerosis grade III was the most common cataract type (37.93%).

Gonioscopy revealed open angles in all patients and PXF in the trabecular meshwork in 60.3%. Intraoperative complications included sphincterotomy (34.5%), zonular dialysis (15.5%), and posterior capsular rent (15.5%). Postoperative complications included inflammation (19%) and raised intraocular pressure (17.24%).

Surgically, 93.2% received posterior chamber IOL, while 6.8% were left aphakic. Postoperatively, 37.93% achieved 6/9 uncorrected visual acuity, and 29.31% achieved 6/12, confirming that MSICS can yield good visual outcomes 

Study Overview

This hospital-based observational study at Amaltas Institute of Medical Sciences, Madhya Pradesh, involved 58 patients with pseudoexfoliation (PEX) undergoing manual small incision cataract surgery (MSICS) over 18 months. The study assessed intraoperative complications, preoperative anterior segment changes, and postoperative outcomes.

Intraoperative Complications

Key intraoperative issues included poor pupil dilation requiring sphincterotomy (34.5%), anterior capsulotomy difficulty (19%), zonular dialysis (15.5%), phacodonesis (12.1%), and posterior capsular rent (15.5%). Vitreous loss occurred in 15.5%, while corneal Descemet membrane peel was seen in 6.9%. Nucleus delivery was difficult in 10.3% of cases. These complications reflect zonular weakness and poor pupillary response in PEX eyes.

Postoperative Complications

Postoperative issues included inflammation (19%), raised intraocular pressure (17.24%), corneal edema (15.5%), pigment dispersion (12.1%), posterior synechiae (3.45%), and intraocular lens (IOL) dislocation (10.3%). Despite challenges, PCIOL implantation was successful in 93.2% of patients.

Visual Outcomes

Most patients achieved good uncorrected visual acuity: 37.93% attained 6/9, 29.31% reached 6/12, and 20.69% had 6/18 vision. The study emphasizes careful surgical planning and postoperative care in PEX cases to achieve satisfactory visual outcomes despite higher complication risks.

In this study, most pseudoexfoliation (PEX) patients were aged 61–70 years, with a slight male predominance. A larger proportion were from rural areas, highlighting gaps in early diagnosis and access to care. PEX affected patients across various socioeconomic classes. Bilateral eye involvement was more common, supporting its systemic nature. Most patients presented with poor preoperative vision, commonly 5/60, often due to delayed surgery. Hypertension was the most frequent systemic comorbidity.

Clinically, pseudoexfoliative material was commonly seen on the pupillary margin with iris atrophy, poor pupil dilation, and sluggish light response. Despite normal preoperative intraocular pressure, lens surface PEX deposits, subluxation, and phacodonesis were observed. Nuclear sclerosis grade III was the most common cataract type. Gonioscopy showed PEX material with open angles in all patients.Intraoperative challenges included sphincterotomy and zonular dialysis. Postoperatively, inflammation, corneal edema, and raised intraocular pressure were common. Posterior chamber intraocular lens (PCIOL) was implanted in most cases, though a few remained aphakic due to complications. Visual outcomes were favorable, with most patients achieving uncorrected visual acuity of 6/9 or 6/12. The study confirms that with careful management, MSICS is effective in restoring vision in PEX patients despite the inherent surgical risks.

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