Corneal Endothelial Alterations in Senile Cataract with and Without Pseudoexfoliation: A Comparative Specular Microscopy Study

Background; Pseudoexfoliation syndrome (PXF) is an age-related systemic microfibrillopathy characterized by the deposition of fibrillar extracellular material in ocular tissues. It is associated with endothelial dysfunction, increased intraoperative complications during cataract surgery, and a higher risk of corneal decompensation. Evaluation of corneal endothelial status using specular microscopy is therefore crucial in patients with PXF.

Objective; To evaluate and compare corneal endothelial cell density (ECD) and endothelial morphology using specular microscopy in senile cataract patients with and without pseudoexfoliation.

Methods;  This prospective, comparative study was conducted at Department of Ophthalmology, Andhra Medical College, Visakhapatnam, from January 2025 to January 2026. A total of 100 patients with senile cataract were included: 50 patients with pseudoexfoliation (PXF group) and 50 age-matched patients without pseudoexfoliation (control group). All patients underwent comprehensive ophthalmic evaluation including slit-lamp examination, intraocular pressure measurement, gonioscopy, and non-contact specular microscopy (Tomey EM-3000). Endothelial cell density (cells/mm²), coefficient of variation (CV%) indicating polymegathism, percentage of hexagonal cells (6A) indicating pleomorphism, and central corneal thickness (CCT) were recorded. Statistical analysis was performed using SPSS software; p < 0.05 was considered statistically significant.

Results; The mean endothelial cell density was significantly lower in the PXF group (2180.20 ± 404.41 cells/mm²) compared to the control group (2695.86 ± 124.94 cells/mm²) (p < 0.0001).

The mean coefficient of variation was higher in patients with PXF (40.90 ± 8.69) compared to controls (37.70 ± 3.99), indicating increased polymegathism.

The mean percentage of hexagonal cells was significantly reduced in the PXF group (40.20 ± 5.44) compared to the control group (44.18 ± 3.98) (p < 0.001), demonstrating increased pleomorphism.

Central corneal thickness was significantly lower in the PXF group (489.02 ± 25.14 µm) compared to controls (513.02 ± 31.43 µm).

These findings indicate significant quantitative and qualitative endothelial alterations in patients with pseudoexfoliation.

Conclusion; Senile cataract patients with pseudoexfoliation demonstrate significantly reduced endothelial cell density, decreased central corneal thickness, and altered endothelial morphology characterized by polymegathism and pleomorphism. Preoperative assessment with specular microscopy is essential in PXF patients to identify those at higher risk of corneal decompensation and to plan appropriate surgical strategies. Careful endothelial evaluation should be considered a mandatory preoperative step in cataract patients with pseudoexfoliation.