Uncomplicated Pseudoexfoliation No Impediment to Successful Cataract Surgery

Since significant complications are more likely associated with eyes that have preexisting pupillary and zonular pathology, experts say it might not be necessary to perform earlier cataract surgery in PEX eyes asymptomatic cataracts. Still, patients should be counseled about the potential for developing loose zonules or small pupils down the line. Photo: Henrietta Wang, BOptom, MPH, and Jack Phu, OD, PhD. Click image to enlarge. Zonular weakness and lens instability are commonly seen in eyes with pseudoexfoliation (PEX) syndrome, a systemic disease that causes the production and accumulation of deposits, especially in the eyes. As an age-related disease, patients with PEX often have cataract as well. However, robust data on late complication rates after cataract surgery in eyes with pre-existing PEX is lacking. To fill this gap, researchers in India made use of the Aravind Eye Care System’s large patient base to prospectively study long-term BCVA and complication rates of IOL decentration and Nd:YAG capsulotomy for posterior capsule opacification in eyes with and without PEX after undergoing cataract surgery. Published recently in the American Journal of Ophthalmology, the Aravind Pseudoexfoliation (APEX) Study spanned 10 years and found comparable late complication rates.The clinical cohort study included 930 study eyes with cataract and PEX without phacodonesis, shallow anterior chambers or a pupil size less than 4mm. A control group of 476 eyes had cataract but without PEX. The researchers randomized eyes to either a single-piece or three-piece acrylic IOL. The PEX group was randomized to capsular tension rings or no capsular tension rings. Follow-up for all eyes occurred at one day, one month, three months, one year and then yearly out to 10 years.Several participants died before study completion (24% of the PEX group and 16.8% of the control group), but at 10 years, follow-up for the remaining participants was over 80% (82.2% for the PEX group and 85.6% for the control group). The researchers reported similar rates of IOL decentration (2.4% and 1.7% in the PEX and control groups, respectively) and Nd:YAG capsulotomy (5.7% and 5.67%, respectively). Risk factors for these two complications were capsular phimosis and capsulorhexis that didn’t overlap the edge of the IOL optic.At 10 years, those in the control group had significantly better logMAR BCVA than those in the PEX group (0.03 vs. 0.12, respectively). The researchers found that capsular phimosis and a capsulorhexis that didn’t overlap the edge of the IOL optic were each independently associated with IOL decentration and a need for capsulotomy.“This is the only long-term, large-scale prospective comparative study using experienced surgeons evaluating both capsular tension rings and IOL types in eyes with PEX, without preoperative and intraoperative zonular weakness and small pupils,” the researchers wrote in their American Journal of Ophthalmology paper. “At 10 years postoperative (most of a life expectancy) we found no differences between eyes with and without uncomplicated PEX and having either one- or three-piece IOLs or capsular tension rings.”The researchers stated in their paper that they’ll continue to evaluate the data. “We will be looking at causes of mortality, incidence of glaucoma and causes of vision loss,” they wrote. “We believe that our study design, large sample sizes and excellent follow-up offer conclusive evidence that eyes with PEX without preexisting phacodonesis or miotic pupils do not need to have capsular tension rings, do not necessarily require earlier cataract surgery, and that either three- or single-piece acrylic IOLs can be safely used in these eyes.”Click here for the journal source. Haripriya A, Chandrashekharan S, Schehlein EM, et al. Aravind Pseudoexfoliation Study (APEX): 10 year prospective results. Am J Ophthalmol 2025. [Epub ahead of print].