# Epidemiology, biometric features and risk factors of pseudoexfoliation syndrome among cataract patients: a hospital-based study in Apulia

## TL;DR

This study finds that pseudoexfoliation syndrome is relatively rare among cataract patients in Southern Italy and not linked to specific eye measurements or inflammation markers.

## Contribution

The study provides new regional prevalence data for pseudoexfoliation syndrome and evaluates its lack of association with biometric features and systemic inflammation markers.

## Key findings

- Pseudoexfoliation syndrome had a prevalence of 2.65% in the Southern Italian cohort.
- No significant associations were found between pseudoexfoliation syndrome and ocular biometric parameters.
- The neutrophil-to-lymphocyte ratio was not linked to surgical complications or biometric features.

## Abstract

to contextualize the prevalence of pseudoexfoliation syndrome (PEX) through a systematic literature review and to evaluate its epidemiology, ocular biometric features, and potential systemic associations in a hospital-based cohort of cataract patients from Southern Italy, with particular focus on the neutrophil-to-lymphocyte ratio (NLR) as a marker of systemic inflammation and surgical risk.

this study consisted of two components. First, a systematic literature review was conducted according to PRISMA principles to summarize reported PEX prevalence across different populations and geographic regions. Second, a retrospective cross-sectional cohort study was performed including consecutive cataract patients evaluated at a tertiary referral center in Apulia (Italy) between January 2024 and September 2025. Demographic data, ocular biometry, corneal parameters, systemic comorbidities, and preoperative NLR values were collected. Eye-level outcomes were analyzed using linear mixed-effects models with patient-level random intercepts, adjusting for age, sex, and eye side. Associations between NLR, biometric parameters, and surgical complications were assessed using correlation analyses and non-parametric tests.In the absence of a pre-specified primary outcome, ACD was selected a posteriori as the primary biometric endpoint.

the literature review confirmed marked heterogeneity in reported PEX prevalence worldwide, ranging from < 1% to > 30%, largely influenced by study design and population characteristics. In the cohort study, 99 of 3,736 cataract patients were diagnosed with PEX, yielding a prevalence of 2.65%. PEX patients were significantly older than non-PEX patients, with no sex predominance. After adjustment, PEX was not independently associated with axial length, anterior chamber depth, aqueous depth, lens thickness, central corneal thickness or endothelial cell density. NLR showed no significant correlation with ocular biometric parameters and did not differ between patients with and without intraoperative or postoperative complications.

PEX was relatively uncommon in this Southern Italian cohort and primarily age-related. No association was found between PEX and standard biometric features or between systemic inflammation (NLR) and surgical risk. Larger, multicenter studies integrating genetic and inflammatory markers are warranted to further elucidate PEX pathogenesis.

Pseudoexfoliation (PEX) is prevalent in older adults and increases intraoperative difficulty during cataract surgery; reported prevalence varies widely across regions and study designs.The neutrophil-to-lymphocyte ratio (NLR) has been proposed as an inflammatory biomarker potentially linked to surgical risk in PEX.

Pseudoexfoliation (PEX) is prevalent in older adults and increases intraoperative difficulty during cataract surgery; reported prevalence varies widely across regions and study designs.

The neutrophil-to-lymphocyte ratio (NLR) has been proposed as an inflammatory biomarker potentially linked to surgical risk in PEX.

In this hospital-based cohort from Apulia, PEX showed a low prevalence (2.65%) among cataract surgery patients.Using linear mixed-effects models (patient-level random intercept) adjusted for age, sex, and eye side, PEX was not independently associated with ACD (primary outcome) and other standard biometric parameters (AL, AQD, LT, CCT).NLR was not associated with ocular biometry or with the occurrence of intra- or postoperative complications.

In this hospital-based cohort from Apulia, PEX showed a low prevalence (2.65%) among cataract surgery patients.

Using linear mixed-effects models (patient-level random intercept) adjusted for age, sex, and eye side, PEX was not independently associated with ACD (primary outcome) and other standard biometric parameters (AL, AQD, LT, CCT).

NLR was not associated with ocular biometry or with the occurrence of intra- or postoperative complications.