Healio lists four pearls for pseudoexfoliation

Healio published a May 20 clinical explainer by cataract surgeon Uday Devgan on how to approach cataract surgery in eyes with pseudoexfoliation syndrome, a condition that can turn routine phacoemulsification into a higher-risk case. Devgan wrote that pseudoexfoliation compromises the lens suspension system, limits pupil dilation and affects aqueous outflow, creating added risk both during surgery and in postoperative pressure control. The article appeared in Healio’s *Cataract Coach* column and was fact-checked by Christine Klimanskis, ELS. ### Why are pseudoexfoliation eyes harder to operate on? Pseudoexfoliation syndrome is associated with two main surgical problems: weak zonules and poor pupillary dilation, according to the American Academy of Ophthalmology and EyeWiki. Those changes increase the risk of intraoperative complications during cataract surgery and can also complicate lens placement and postoperative management. (healio.com) Healio described pseudoexfoliation as a systemic basement membrane disorder that affects the structural integrity of the lens suspension system, pupil dilation and aqueous outflow pathways. Devgan wrote that success depends on anticipating zonular failure before it becomes an intraoperative crisis. ### What was the first pearl Devgan highlighted before surgery starts? (aao.org) Devgan’s first pearl was preoperative recognition at the slit lamp. He wrote that surgeons should look for pathognomonic fibrillar deposits on the anterior lens capsule, with the most important clue being a “zone of clearing” where the iris has rubbed material off the capsule during pupil movement. (healio.com) That pattern matters because it warns that the zonules may already be brittle and prone to breaking under stress, Devgan wrote. AAO materials on pseudoexfoliation similarly identify zonular weakness as a major driver of surgical risk in these eyes. ### What does the surgeon look for at the first touch of the capsule? (healio.com) Devgan’s second pearl focused on the initial puncture of the anterior capsule. In a healthy eye, he wrote, the capsule has the tension of a “drumhead,” but in pseudoexfoliation the zonules can behave like “old rubber bands” with lost recoil. During capsulotomy entry, Devgan said surgeons should watch for radial wrinkles or striae around the needle or cystotome. (healio.com) He wrote that those signs confirm zonular weakness, and in severe cases the entire lens complex may shift when the instrument presses on it. ### What does that change once the case is underway? Devgan wrote that early recognition allows surgeons to adjust fluidics and prepare support devices rather than being surprised later by a wobbling lens. (healio.com) EyeWiki’s guidance on capsular support devices likewise says such devices should be considered when zonular weakness is suspected, including in pseudoexfoliation syndrome. AAO and EyeWiki references also note that pseudoexfoliation cases may require a tailored surgical plan because poor dilation and unstable zonules can coexist in the same eye. That makes intraoperative planning — including readiness for pupil expansion or capsular support — part of the risk management rather than a rescue step. ### What are the remaining takeaways for surgeons and trainees? (healio.com) Healio framed Devgan’s four pearls as stage-specific guidance for navigating high-risk pseudoexfoliation cases with greater predictability. The article’s emphasis was not on a new device or trial result, but on pattern recognition, early confirmation of lax zonules and planning before instability escalates. (aao.org) The explainer remains available in Healio’s ophthalmology coverage and *Cataract Coach* archive, where Devgan’s May 20 article is listed for the May 25, 2026 issue. (healio.com)