BACKGROUND: Hydrodissection was recently reported to occur more easily in patients with exfoliation syndrome (XFS). Transmission electron microscopy studies have already revealed alterations of the lens epithelial cells (LECs) and their apical membrane towards the lens fibers.OBJECTIVE: To examine the three-dimensional (3D) appearance of the lens epithelium in patients with XFS.METHODS: Fourteen patients with senile cataract, seven of whom with XFS, were included. Anterior lens capsules (aLCs) were obtained with continuous curvilinear capsulorrhexis (CCC) during phacoemulsification and were examined with scanning (SEM) and transmission electron microscopy (TEM).RESULTS: Exfoliation samples exhibited an overall more irregular apical surface of the lens epithelium, compared to control aLCs. The LECs' height varied extensively. On the LECs' apical surface amorphous, crystalline-like or microgranular extracellular material and membranous, oval-shaped structures were documented with SEM. All findings were connected to corresponding observations with TEM and were not correlated to the type of cataract.CONCLUSIONS: In XFS patients, the lens epithelial surface exhibited a highly irregular margin, with extracellular material covering the LECs' apical membrane. We suggest that XFS probably causes both epithelial and lens fibers' degeneration which, during CCC and mechanical extraction of the aLC from the lens cortex, result in diverse alterations.