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

PURPOSE: 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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.