Cataract Surgery in Pseudoexfoliation: Pearls and Pitfalls

Last updated: October 2026

Short answer: pseudoexfoliation (PXF) makes cataract surgery riskier because the pupil dilates poorly and the zonules are weak. Plan for pupil expansion, make an adequately sized capsulorhexis, minimise stress on the zonules, and use a capsular tension ring when there is zonular weakness. Watch for IOP spikes after surgery and late IOL dislocation years later.

Why PXF eyes are challenging

• Poor dilation: the iris is stiff and the pupil often dilates poorly.
• Weak zonules: higher risk of zonular dialysis, posterior capsule rupture and vitreous loss.
• Glaucoma: PXF is a common cause of secondary open-angle glaucoma, and IOP spikes after surgery are common.
• Late problems: capsular phimosis (contraction) and in-the-bag IOL dislocation, which can occur years later.

Before surgery: look for warning signs

• Phacodonesis (lens wobble) or iridodonesis on eye movement
• A shallow or uneven anterior chamber compared with the other eye
• Poor dilation in the clinic
• A dense nucleus (more stress on the zonules during removal)
• Have capsular tension rings, capsular hooks and pupil expansion devices ready.

During surgery

• Pupil: use a pupil expansion ring (for example, a Malyugin ring) or iris hooks if the pupil is small. Avoid working through a tiny pupil.
• Capsulorhexis: aim for an adequately sized rhexis (about 5–5.5 mm). A small rhexis increases the risk of capsular phimosis later.
• Hydrodissection: gentle and thorough, so the nucleus rotates easily without pushing on the zonules.
• Nucleus removal: techniques that use less force on the bag, such as chopping, reduce zonular stress. Rotate the nucleus gently with two instruments.
• Capsular tension ring (CTR): use it when there is zonular weakness. It spreads the force around the capsular equator, supports the bag and helps keep the IOL centred.
• For more severe weakness, capsular hooks or segment devices may be needed; significant weakness may require a sutured or scleral-fixated IOL.

After surgery

• Check IOP on the first post-operative day and treat spikes promptly.
• Control inflammation; PXF eyes often have more breakdown of the blood–aqueous barrier.
• Watch for anterior capsular phimosis; Nd:YAG relaxing incisions in the anterior capsule can prevent it worsening.
• Tell patients about the risk of late IOL dislocation, and ask them to return if vision suddenly changes.

Frequently asked questions

Related: pseudoexfoliation syndrome, phaco step by step and PCR management flowchart.