Patients with pseudo-exfoliation (PXF) syndrome are known to have deposits of fibrillar material throughout the anterior segment. This is most easily seen on the anterior lens capsule, but it also occurs on the iris, in the angle, and elsewhere. These patients are known to have multiple issues during cataract surgery such as weak zonular support and poor dilation. In addition these patients have a higher risk of glaucoma.
A previous article / video published here on CataractCoach provides useful pearls in doing cataract surgery in these patients: principles of Pseudo-Exfoliation Cataract Surgery
The video in this article is cataract surgery done by a resident in training where there is extensive fibrillar pseudo-exfoliation material seen on the anterior lens capsule. Since this is also a white/opaque cataract, trypan blue dye was used to stain the capsule and highlight this PXF material. With microscope-mounted optical coherence tomography (OCT), we can scan the lens capsule and examine this fibrillar material.
The OCT scan clearly shows this material on the anterior lens capsule, but more importantly, it also shows a very positive finding that there is no gap between the iris and crystalline lens. We can often correlate the pupil size to the degree of zonular weakness induced by PXF, and a gap between the iris and the anterior lens capsule can mean significant zonular weakness is present. With our patient in the supine position for surgery, loose zonular support would allow the lens to shift posterior, creating this gap.
click below to learn from this PXF Cataract Surgery: