The purpose of the study is to evaluate the risk factors associated with exfoliation in a case-cohort setting and literature review. This single-center, prospective, case-cohort study was carried out from January 2010 to April 2020 on patients operated for cataract surgery by a single surgeon in Lebanon. Forty-nine consecutive patients with exfoliation syndrome (XFS) and 62 consecutive control patients were identified and further investigated for selected systemic (diabetes mellitus, systemic hypertension, asthma, or atopy) and ocular variables (baseline vision, severity of nuclear sclerosis, glaucoma, eye rubbing, history of dry eye, or allergic eye disease). The mean baseline Snellen visual acuity was 20/283 in XFS versus 20/145 in control cases ( P = 0.012). XFS also demonstrated significantly denser nuclear sclerosis than controls ( P = 0.00958). By univariate analysis, allergic conjunctivitis (15 [30.6%] vs. 2 [3.2%]; P < 0.001), dry eye (20 [40.8%] vs. 13 [21.0%]; P = 0.0133), and habitual rubbing of the eyes (33 [67.3%] vs. 19 [30.6%]; P < 0.001) were associated with the presence of XFS. Habitual ocular rubbing was closely associated with allergic conjunctivitis (odds ratio [OR] = 13.0; 95% confidence interval [CI]: 2.8–58.8; P = 0.032). After multivariable analysis, the following variables showed significant results: glaucoma (OR = 34.5; 95% CI: 4.4–250; P = 0.010), duration of surgery (OR = 5.6; 95% CI 2.43–12.9; P < 0.001), and habitual ocular rubbing (OR = 4.42; 95% CI: 1.97–9.90; P = 0.029). This study shows a novel potential correlation between eye rubbing and XFS in a Lebanese cohort. Chronic eye rubbing induces or may exacerbate preexistent zonular damage in subjects with XFS, hence the need to better manage concurrent ocular surface disorder in these patients.

Purpose: To determine the patient-related factors that contribute to surgeon stress during phacoemulsification cataract extraction (PCE) performed under unassisted topical anesthesia. Methods: This is a prospective study of perceived surgeon stress during phacoemulsification by a single surgeon of consecutive patients undergoing PCE. At the conclusion of each procedure, the surgeon recorded the perceived stress according to the following three indices: surgeon score, qualitative score (yes or no), and total score (sum of itemized causes of stress). Patient variables included in the analysis included gender, age, diabetes mellitus, morbid obesity, intake of oral alpha blockers, floppy iris, laterality, pseudo-exfoliation, intraocular lens power, and initial visual acuity. Results: During the 10-year study, 1097 eyes underwent surgery. The following patient variables were seen frequently: floppy iris syndrome (92), pseudo-exfoliation (72), and morbid obesity (36). Surgeon identified stress was reported after 250 procedures. On multivariable analysis, the following patient characteristics were associated with surgeon stress: age >80 years; morbid obesity; floppy iris syndrome; severe nuclear sclerosis; and poor baseline distance corrected visual acuity. Conclusion: Several ocular and systemic patient-related characteristics contribute to surgeon stress during PCE.

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