When True Meets Pseudo: Histopathologic Evidence Of Dual Exfoliation In The Lens Capsule

To describe the coexistence of true exfoliation with pseudoexfoliation (PEX) syndrome in three eyes of two patients, confirmed histopathologically, and to highlight their clinical and surgical implications.

Cornea and Pathology Departments, Hôpital Ophtalmique Jules-Gonin, University of Lausanne, Switzerland.

Case 1: A 78‑year‑old male winemaker presented for cataract assessment. His history included pseudoexfoliation syndrome without glaucoma. Preoperative slit‑lamp exam revealed combined pseudoexfoliative and true exfoliative processes in both eyes. Best corrected visual acuity (BCVA) was 0.4 (−3.50/−0.50 × 101) OD and 0.8 (−1.75/−2.75 × 78) OS. Intraocular pressures were 12 mmHg OD and 15 mmHg OS. Both irides showed PEX deposits and the lenses exhibited capsular pseudoexfoliation with lamellar delamination consistent with true exfoliation. The patient reported ocular heat exposure during welding in 2010. Cataract surgery was uneventful in both eyes, and histopathology of the anterior capsule confirmed coexistence of pseudoexfoliation and true exfoliation.

Case 2: A patient referred for cataract extraction reported progressive visual decline over one year. BCVA measured 1.25 (+1.25/−0.50 × 94) OD and 0.5 (−0.50/−0.75 × 96) OS, with mild myopic shift in the left eye. Intraocular pressures were normal. Slit‑lamp exam revealed PEX material on the pupillary margins and lens surface, with anterior capsule delamination and a 3+ nuclear, 1+ cortical cataract in the left eye. Patient denied previous thermal exposure. The anterior capsule excised during phacoemulsification was sent for histopathology, which again confirmed pseudoexfoliation with true exfoliation. Postoperative recovery was uneventful with good visual improvement.

These two cases illustrate the coexistence of true exfoliation and pseudoexfoliation in the same eye, verified histopathologically in three eyes. This rare association may occur even without significant thermal exposure. Awareness of this finding is important for surgical planning and for deepening the insight into the mechanisms of lens capsule degeneration.