Predicting zonular strength based on maximum pupillary mydriasis in patients with pseudoexfoliation syndrome

Pseudoexfoliation Syndrome (PXFS) is considered a systemic disorder with significant ocular manifestations ranging from corneal decompensation, non-dilating pupil, zonular weakness, subluxated lens, and glaucoma. PXFS may lead to increased complications during routine cataract surgery. Zonular dialysis is a common complication during or after cataract surgery in such patients. However, not all patients with pseudoexfoliation are at a higher risk. We hypothesize that there is an inverse correlation between the maximum pupillary dilation and the degree of zonular disintegration. Available evidence supporting the hypothesis is discussed. We propose a new clinical classification for predicting the zonular strength based on the maximum pupillary dilation so that it can serve as a guide to identify PXFS patients who are at high risk of complications during or after cataract surgery.