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Purpose: To visualize structural alterations of the cornea, iris, and lens in patients with exfoliation syndrome (XFS) using a noncontact in vivo laser scanning confocal microscope and to correlate these with the clinical features. Methods: The cornea, iris, and lens of 30 eyes with XFS were imaged using the Rostock Cornea Module of Heidelberg Retina Tomograph II (50 × noncontact Nikon lens, an estimated 1 to 2 µm transverse resolution, 500×500-µm field of view). Serial transverse section images, as well as anterior segment photographs, were taken and analyzed. Results: The corneal stroma and endothelium of 19 eyes (63%) showed different amounts and sizes of scattered small hyperreflective deposits. The irides revealed hyperreflective deposits on the anterior outer surfaces and/or pupillary margin corresponding to exfoliation material (XFM) and/or pigment granules. The anterior lens capsule showed varying degrees of peripupillary fibrillar hyperreflective deposits, hyperreflective areas with apparent epithelial cells centrally, and uniform epithelial cells in the clear intermediate zone. On the anterior capsule in 4 pseudophakic eyes, XFM appeared as hyperreflective round deposits. Hyperreflective floating deposits were seen in the aqueous humor in the pupillary region of the posterior chamber of 6 eyes (20%). Conclusions: Noncontact in vivo confocal microscopy permits visualization of XFM in the cornea, iris, and lens. This new technique may improve early detection of anterior segment abnormalities by providing information about subclinical cellular pathology, such as early pregranular XFS. Trans Am Ophthalmol Soc 2008;106:46-5