Investigation of Risk Factors Predicting Cataract Surgery Complications in Patients with Pseudoexfoliation Syndrome: A Systematic Review

Author: Preoteasa LD, Baltă G, Baltă FN.

Geographical coverage: Asia and Europe

Sector: Cataract surgery

Sub–sector: Risk factors, complications

Equity focus: Not reported

Study population: Patients with cataract

Review type: Effectiveness review

Quantitative synthesis method: Meta-analysis

Qualitative synthesis method: Not applicable

Background:

Pseudoexfoliation syndrome (PXF) is a multifactorial condition with complex ocular and systemic manifestations. It is most prevalent in older populations, with notable geographical and ethnic variation. Characterised by the accumulation of fibrillar material, PXF can lead to zonular instability, lens dislocation and glaucoma, and is also associated with systemic disorders such as cardiovascular disease, diabetes and renal dysfunction. During cataract surgery, PXF increases the risk of complications; however, not all affected individuals experience adverse outcomes. Identifying patient‑level risk factors is therefore essential, as complications can impair visual results, increase healthcare costs and diminish quality of life.

Objective:

To identify pre‑operative risk factors that can distinguish pseudoexfoliation patients who are likely to develop intra‑ or postoperative complications during cataract surgery from those at low operative risk.

Main findings:

The review included six studies comprising 999 eyes with pseudoexfoliation syndrome, conducted in China, Germany, Japan, Turkey, Israel and Spain (one study each). Methodological quality was judged high in two studies, low in two and unclear in the remaining two.

Complications were categorised as intra‑operative (e.g. zonular dialysis, vitreous loss, posterior capsular rupture) or postoperative (e.g. corneal oedema, endothelial cell loss, intra‑ocular lens dislocation, capsular phimosis).

Five pre‑operative risk factors were statistically associated with a higher incidence of complications:

• Shallow anterior chamber depth (ACD)** – particularly < 2.5 mm – increased the risk of intra‑operative issues such as vitreous loss (odds ratio [OR] 13.4; *p* = 0.013).
• Advanced cataract** (Emery–Little classification) was linked to greater endothelial cell loss and other postoperative complications (OR 4.16 for corneal oedema; *p* = 0.001).
• Raised neutrophil‑to‑lymphocyte ratio (NLR)** – values above 2.33 – strongly predicted intra‑operative complications, supporting a role for systemic inflammation.
• Elevated pre‑operative intra‑ocular pressure (IOP)** – > 23 mmHg – significantly predicted phacodonesis, indicating lens instability.
• Bilateral, symmetrical PXF** correlated with a higher risk of both intra‑operative and long‑term postoperative complications.

Methodology:

Searches were performed in PubMed/MEDLINE, Scopus, SpringerLink, ScienceDirect, Web of Science, the Cochrane Database of Systematic Reviews, TRIP, LILACS and ClinicalTrials.gov for studies published between 2000 and 2023. Studies were eligible if participants were aged 40 years or over and if they reported a statistical association between exposure and clinical course. No restrictions were applied to sex, country, ethnicity, publication language or sample size. Reference lists of included studies were also screened for additional publications.

Two reviewers independently extracted data and assessed risk of bias using guidance from the Cochrane Handbook; disagreements were resolved through discussion or, when necessary, consultation with a third reviewer. The certainty of evidence was appraised with GRADE. Findings were synthesised using fixed‑ or random‑effects models according to heterogeneity, which was quantified with the I² statistic.

Applicability/external validity:

Substantial heterogeneity, small sample sizes, methodological limitations and inconsistent outcome definitions limit generalisability. Rigorous future research is required to validate these associations and refine pre‑operative assessment protocols.

Geographic focus:

No geographical limits were applied. Of the six included studies, four were conducted in Asia and two in Europe.

Summary of quality assessment:

Overall confidence in the conclusions is low. Searches were comprehensive, inclusion and exclusion criteria clearly defined, and two reviewers independently extracted data and assessed risk of bias. Study characteristics were documented, meta‑analyses appropriately performed and heterogeneity addressed. However, the review did not specify how many reviewers undertook the initial screening and did not provide a list of excluded studies.