**Background:** Pseudoexfoliation syndrome (XFS) is an age-related systemic disease characterized by deposition of extracellular fibrillar material in various tissues, including the eye. Pseudoexfoliative glaucoma (XFG) is a common secondary open-angle glaucoma often associated with elevated intraocular pressure (IOP), but normotensive variants exist. Vascular dysfunction is thought to play a role in glaucoma pathogenesis, and nailfold videocapillaroscopy (NVC) is a non-invasive technique to assess microcirculation in vivo. This study aimed to evaluate NVC findings in XFG patients and explore relationships with clinical status.
**Methods:** The study included 39 Polish Caucasian XFG patients (69 eyes) and 32 age- and gender-matched controls. XFG patients were subdivided into hypertensive XFG (hXFG, peak IOP >21 mmHg, n=29 patients) and normotensive XFG (nXFG, peak IOP ≤21 mmHg, n=10 patients). Exclusion criteria included diabetes, hypertension, connective tissue diseases, and other glaucoma types. NVC was performed by a single experienced specialist blinded to group assignment, using a VideoCap 3.0 at 200× magnification on the 2nd–5th fingers of both hands. Capillary parameters assessed included background, architectural arrangement, number, dilatation, tortuosity, glomerular capillaries, neoangiogenesis, microhemorrhages, aneurysmal dilatations, and avascular areas. NVC patterns were classified as normal (within normal limits or with few tortuous capillaries) or abnormal (features of microangiopathy, e.g., prevalent tortuous capillaries, enlarged capillaries with microhemorrhages, or neoangiogenesis). Statistical analysis used chi-square, Kruskal-Wallis, and Spearman tests, with p≤0.05 considered significant.
**Key Results:** There was no significant difference in the prevalence of abnormal NVC patterns between the XFG group (33.33%) and controls (35.19%, p=0.8773). Architectural derangement of capillaries was significantly more common in XFG patients (33.3%) than controls (9.38%, p=0.0332). A decreased number of capillaries was observed only in nXFG patients (10.0%) and not in hXFG or controls (p=0.0297). Tortuous capillaries were significantly less frequent in the XFG group (41.03%) compared to controls (53.13%, p=0.0386), and even less so in nXFG (30.0%) vs. controls (p=0.0171). Microhemorrhages were present in 30.0% of nXFG patients vs. 6.25% of controls (p=0.0520), and in 17.95% of the total XFG group. Dilatation of capillaries was observed in 28.21% of XFG, 30.0% of nXFG, 27.59% of hXFG, and 37.5% of controls. Aneurysmal dilatations were seen in 20.0% of nXFG, 10.34% of hXFG, 12.82% of XFG, and 12.5% of controls. No significant correlations were found between NVC pattern and age, cup-to-disc ratio (c/d), best corrected visual acuity (BCVA), time of treatment, visual field defect type, mean deviation (MD), or maximal IOP. However, the highest maximal IOP (30.1±17 mmHg) and most advanced VF defect (MD: −16.4±13.6 dB) were observed in patients with a prevalent number of tortuous capillaries, while the lowest maximal IOP (16.3±5.8 mmHg) was seen in those with capillary dilatation and microhemorrhages.
**Clinical Implications:** This study demonstrates that specific NVC features differentiate normotensive from hypertensive XFG patients. The tendency for microhemorrhages and decreased capillary number in nXFG resembles patterns previously described in normal-tension glaucoma (NTG), suggesting that vascular dysregulation may contribute to optic neuropathy in these patients even without elevated IOP. The finding that tortuous capillaries were less common in XFG overall, but more prevalent in advanced glaucoma, indicates that capillary tortuosity may reflect progressive microvascular damage. These results support the hypothesis that vascular factors, possibly related to pseudoexfoliative material deposition in vessel walls, elevated homocysteine, or altered LOXL1 expression, play a role in XFG pathogenesis. NVC may serve as a non-invasive tool to identify XFG patients with a vascular component to their disease, potentially guiding personalized treatment strategies that address both IOP and microcirculatory health. Further studies using OCT angiography are warranted to correlate nailfold capillary changes with retinal and optic nerve head vasculature.