Capsule-splitting phenomenon during capsulorhexis in pseudoexfoliation

We present the case of a 78-year-old white woman with a 2+ nuclear sclerotic cataract and pseudoexfoliation syndrome who had cataract extraction with intraocular lens implantation. The initial continuous curvilinear capsulorhexis (CCC) was performed with a cystotome. Due to unusual tearing characteristics, there was concern that the anterior flap was pseudoexfoliative material instead of the lens capsule. Trypan blue was instilled in the anterior chamber, and the staining pattern indicated that the anterior capsule flap had failed to fold on itself initially. A CCC was initiated in the reverse direction and completed without complication. This case illustrates the importance of recognizing the potential for the capsule-splitting phenomenon when performing a CCC in patients with pseudoexfoliation and the important role for capsule staining in these patients.