Anterior Segment Parameters As Predictors Of Intraoperative Management In Pseudoexfoliation Cataract Surgery: Associations With Phacoemulsification Metrics, And Complications

To evaluate intraoperative outcomes in pseudoexfoliation (PSX) cataract surgery and to identify preoperative corneal topography– and anterior segment–derived risk factors associated with phacoemulsification metrics, intraoperative management (capsular stabilization and pupil expansion), and intraoperative complications.

Single-center retrospective study conducted at the Department of Ophthalmology, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Türkiye.

This retrospective study included eyes with pseudoexfoliation syndrome (PSX) undergoing phacoemulsification cataract surgery. Preoperative and last follow-up assessments included optical biometry (Lenstar LS 900), corneal topography with Pentacam HR, specular microscopy, best-corrected visual acuity, autorefraction, and intraocular pressure measurement. Intraoperative phacoemulsification metrics (cumulative dissipated energy [CDE], total ultrasound time, aspiration time, total aspirated fluid volume, and total case time) were recorded. Intraoperative floppy iris syndrome (IFIS), iris ring use, capsular tension ring (CTR) implantation, and intraoperative complications were recorded from operative notes.

A total of 136 PSX eyes were included (mean age:74.25±7.41 years).IFIS was observed in 51 (37.5%) cases.Iris ring and Y-hook were used in 25 (18.4%) and 17 (12.5%) cases.CTR was implanted in 19 (14.0%) cases and intraoperative complications occurred in 12 (8.8%) cases.Case time was 20.64±12.06 minutes and mean total CDE was 13.08±9.53.Mean ACD was 2.51 ± 0.44 mm.Deeper ACD was associated with greater phaco energy demand (p=0.0017) and longer ultrasound use (p=0.010).Very shallow ACD (<2.07 mm) was associated with higher CTR use (p=0.038).Although IFIS was not associated with higher CDE (p=0.094),it was significantly associated with increased iris ring use (p=0.001) and showed a trend toward higher intraoperative complications (p=0.060).

In our study, a deeper ACD was associated with higher CDE. This association may reflect case characteristics that increase energy demand in PSX eyes (e.g., cataract density) as well as underlying zonular weakness; in contrast, the need for a CTR, a more direct indicator of zonular instability, was more strongly associated with a very shallow ACD. In PSX cataract surgery, preoperative anterior segment morphometry may be a key predictor of intraoperative challenges.