Capsular Tension Ring Use In Pseudoexfoliation Cataract Surgery: 15-Year Real-World Outcomes From A Tertiary Eye Hospital

Pseudoexfoliation (PXF) is associated with zonular weakness and increased risk of intraoperative and late capsular bag–IOL complex complications. Capsular tension rings (CTRs) are commonly used to improve intraoperative stability, but evidence for long-term benefit in PXF remains mixed. We evaluated whether CTR insertion during phacoemulsification in eyes with PXF is associated with improved intraoperative safety and postoperative outcomes compared with PXF eyes without CTR implantation.

Moorfields Eye Hospital NHS Foundation Trust, London, UK, a tertiary referral eye hospital. Consecutive phacoemulsification with intraocular lens implantation procedures performed between 2010 and 2025 in eyes documented to have pseudoexfoliation.

Retrospective cohort study of all phacoemulsification + IOL procedures (2010–2025) in patients with documented pseudoexfoliation. Operative records and clinical notes were reviewed to identify CTR insertion. Eyes were grouped as PXF+CTR versus PXF without CTR. Baseline demographics and ocular risk factors (including markers of zonular weakness where documented) were extracted. Outcomes compared between groups included intraoperative complications (e.g., zonular dialysis, posterior capsule rupture/vitreous loss), early postoperative complications, and longer-term capsular bag/IOL complex events (e.g., pseudophacodonesis, capsular phimosis, IOL decentration/dislocation) plus visual outcomes where available.

A total of 4,200 PXF eyes underwent phaco+IOL; 256 (6.1%) had a CTR inserted. Follow-up varied from approximately 1 to 15 years. Overall, 37/4,200 (0.88%) underwent vitrectomy during follow-up. Vitrectomy for a subluxed IOL/capsular bag complex occurred in 12/4,200 (0.29%). Of these 12 cases, 7 occurred in the CTR group: 7/256 (2.7%) versus 5/3,944 (0.13%) without CTR.

In this large real-world PXF cohort, vitrectomy for late IOL/bag complex subluxation was rare overall (0.29%). Events were disproportionately represented among eyes receiving CTRs, most likely reflecting selection of CTR for eyes with greater baseline zonular compromise, rather than a protective effect against clinically significant late instability. These findings reinforce that CTR use alone may not eliminate the risk of late bag–IOL failure in high-risk PXF eyes and highlight the need for risk-adjusted analyses using documented zonular/pupil/complexity markers, alongside consideration of additional capsular support strategies and patient counselling about residual late-dislocation risk.