Cataract surgery can be performed in pseudoexfoliation cases without expansion devices

Patients with pseudoexfoliation syndrome pose significant challenges during cataract surgery: The zonular apparatus is often weak with some degree of phacodonesis, and the pupil tends not to dilate well, limiting access to the cataract. These eyes are at a higher risk of both intraoperative and postoperative complications, which can result in compromises in visual recovery. The technique of cataract surgery in these eyes with small pupils has traditionally involved the use of mechanical pupil expanders such as iris hooks or rings, but there is an alternate method to achieve an excellent and safe outcome.Our patient comes in for consultation after failing the vision test for his driver’s license renewal. He presents with 2 to 3+ nuclear cataracts in both eyes, which are limiting his best corrected vision to 20/50 and even worse with glare testing. Preoperatively his maximum pupil dilation is 4 mm in diameter, and he is noted to have an axial length of 23 mm with an anterior chamber depth of 2.8 mm in each eye. Because the anterior chamber depth is reasonable and not shallow, we can surmise that the zonular apparatus is in reasonable shape without too much laxity. A pearl that I learned from Alan Crandall, MD, is to beware of a shallow anterior chamber in patients with pseudoexfoliation because it usually means that the entire lens-iris diaphragm is loose and pushing forward, thereby shallowing the anterior chamber.