Surgical Outcomes and Complication Profile of Cataract Surgery in Eyes With Pseudoexfoliation Syndrome: A Prospective...

Background and aim Pseudoexfoliation syndrome (PXS) substantially elevates the technical complexity of cataract surgery through its twin mechanisms of restricted pupillary dilation and progressive zonular weakness. This study aimed to document the intraoperative complication spectrum and postoperative visual rehabilitation following small incision cataract surgery (SICS) with intraocular lens (IOL) implantation in eyes with concurrent PXS and to identify preoperative predictors of adverse surgical outcomes. Methods This prospective observational study enrolled 50 consecutive eyes of 50 patients with coexisting visually significant cataract and PXS at a tertiary ophthalmology center in Bihar, India. All patients underwent manual SICS with primary polymethyl methacrylate (PMMA) IOL implantation by a single surgeon, and outcomes were evaluated at three months. Preoperative pupillary dilation category was assessed as the primary predictor of intraoperative complications. Best-corrected visual acuity (BCVA) was recorded at baseline and at the three-month follow-up visit. Statistical associations were evaluated using chi-square and nonparametric tests, and a p-value <0.05 was considered significant. Results The cohort was predominantly male (31 (62%)) and elderly (29 (58%) aged above 70 years; mean age, 70.4 ± 8.6 years). Poor pharmacological mydriasis (pupil 3-5 mm) was recorded in 13 (26%) eyes. Intraoperative complications included difficulty with anterior capsulotomy in nine (18%) eyes, posterior capsular rent in five (10%), zonular dehiscence in four (8%), and vitreous loss in four (8%). All complication rates correlated significantly with inadequate pupillary dilation (p < 0.05). Postoperatively, 36 (72%) eyes attained a BCVA ≥ 6/18, representing a statistically significant improvement over the preoperative distribution (p < 0.001). Posterior capsular opacification in nine (18%) and cystoid macular edema in four (8%) were the leading causes of suboptimal visual rehabilitation. Conclusions Although PXS significantly amplifies surgical risk relative to routine cataract cases, structured preoperative planning, maximal pupillary dilation, and appropriate intraoperative adjuncts consistently yield visual outcomes comparable with published benchmarks. Preoperative pupillary dilation status is a robust, statistically significant predictor of intraoperative morbidity and should guide surgical strategy.