“Dead bag syndrome” is a real problem. One needs to understand why it happens and how to manage it. My guests in this column are Ehud I. Assia, MD, a great surgeon and innovator, and Veronika Yehezkeli, MD.

Amar Agarwal, MS, FRCS, FRCOphth OSN Complications Consult Editor

Posterior dislocation of a capsular-fixated posterior chamber IOL through a defect in the posterior capsule years after implantation is rare. It is almost always associated with capsular pathology or severe ocular trauma. Spontaneous rupture of the intact posterior capsule, with no history of even minor trauma, is most unlikely.

Four years ago, we examined a 70-year-old patient who underwent routine and uneventful cataract surgery 17 years earlier with postoperative visual acuity of 20/20. During the follow-up, the posterior capsule was documented as intact, and the posterior chamber IOL was central and stable. In February 2017, he experienced an acute drop of vision, and the posterior chamber IOL was seen posteriorly dislocated into the vitreous cavity through a large vertical tear in the posterior capsule. He denied any trauma, laser treatment or even rubbing his eyes. The lens capsule was clean with no signs of posterior capsule opacification or Nd:YAG capsulotomy. The patient was treated by repositioning of the posterior chamber IOL and scleral fixation using 9-0 Prolene sutures. He regained uncorrected 20/25 vision in the 1-month postoperative visit.

Since then, we observed and treated three more similar cases, and because of the unusual pattern of the spontaneous rupture of the clear posterior capsule, we published these four cases in 2021. Since this publication, we recently treated one more patient with the same course and clinical findings. All five cases exhibited an almost identical pattern: They were all men, and they underwent routine and uneventful phacoemulsification 15 to 20 years earlier, with implantation of the same type of hydrophilic acrylic IOL (B-Lens, Hanita Lenses). There was no evidence of capsular or zonular pathology and no history of significant eye trauma. In all cases, the posterior capsules were clear and clean with no signs of posterior capsule opacification or fibrosis and no evidence of Nd:YAG laser treatment. The IOLs were all dislocated, partially or completely, behind the posterior capsules through an equator-to-equator capsule break. One patient had a retinal detachment surgery with successful reattachment and documented intact capsule for 16 years. Another patient had episodes of anterior uveitis that responded well to conservative medical treatment.

The most unusual finding was the clear, transparent posterior capsule with no evidence of fibrosis or capsular adhesions. This explains why the lenses dislocated posteriorly through the capsular defect as there were no capsular adhesions to hold and support the IOL.

My personal preference in cases of subluxated/dislocated IOLs is to reposition the same IOL because optically the lens is not affected by time. In our cases, I used five different techniques to reposition the same IOLs: sulcus fixation, iris suture fixation and scleral fixation using 10-0 and 9-0 Prolene sutures through the lens material, and 6-0 Prolene sutures using the adjustable flange technique (Figure 1). In all cases, the IOLs were central and stable postoperatively, and effective vision was restored.

Recently, Culp and colleagues published a paper entitled “Clinical and histopathological findings in the dead bag syndrome.” The authors describe 10 clinical cases and histopathological findings of seven capsular bags and five explanted IOLs. These cases share a similar clinical course and physical findings to our cases, most notably clear and fragile posterior capsules. Posterior chamber IOL malposition was evident following nontraumatic capsule rupture many years (average, 10.6 years) after cataract surgery. In some cases, the IOL subluxated initially inside of the capsular bag, most likely through a peripheral defect. The IOLs were either three-piece silicone or one-piece hydrophobic acrylic lenses with no apparent defects. Lens epithelial cells were either completely absent or rare, with histological evidence of capsular splitting and thinning. This clinical pattern was termed dead bag syndrome, indicating that loss of epithelial cells may result in long-term structural changes of the lens capsule, leading to increased fragility and its spontaneous rupture.

In theory, if all epithelial cells are removed or killed during the initial surgery, the rate of late capsule rupture and IOL dislocation may significantly increase. The cause of late cell death is not clear, and apparently IOL material and design are not major factors. In our series, all lenses were of the same material (hydrophilic) and design; however, these lenses were popular 20 years ago. In the U.S. series, the lenses were either silicone or hydrophobic acrylic one- or three-piece design. Six out of eight explanted patients in the U.S. study and all five of our patients were men. This finding is also not clear.

Dead bag syndrome is a newly described entity that should be recognized by eye surgeons. With the increasing indications of cataract surgery or clear lens extraction, and the longer lifespan of the general population, we should expect to see more of these cases in the future.

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