CATARACT EWAP SEPTEMBER 2022 23 has been coined “dead bag syndrome.” Dr. Mamalis was a co-author on a paper published earlier this year in the Journal of Cataract & Refractive Surgery that examined the clinical and histopathological findings of capsular bags and IOLs from dead bag syndrome cases.1 “These capsules were crystal clear, and when we look at them under pathological analysis, we found there was a splitting of the capsule,” Dr. Mamalis said. “There will be an absence of lens epithelial cells, absence of proliferative cortical material. In terms of why this is happening, at this point we can only speculate as to the real reason. … It’s known that the lens epithelial cells that normally reside even after cataract surgery in the capsular fornix have some factors that act to maintain the capsular bag. … In these cases, the lens epithelial cells are completely absent for reasons we don’t understand.” Dr. Mamalis emphasized that while the capsular bag-IOL complex dislocates with dead bag syndrome, it is a different entity than late spontaneous lens dislocation. Prevention and treatment From a prevention standpoint, Dr. Safran said it’s important to do atraumatic surgery. He also said to clean out the bag well, removing epithelial cells that could lead to fibrotic contraction that pulls on zonules. If there is evidence of pseudoexfoliation or weak Spontaneous intraocular lens (IOL) dislocation can occur as a result of postoperative zonulysis or posterior capsule (PC) rupture. The former results in an unstable lens–capsular bag complex, while the latter causes IOL instability due to deficient posterior capsule support. Atraumatic etiologies for postoperative zonulysis include pseudoexfoliation, high axial myopia, previous vitreoretinal surgery, and uveitis. Atraumatic PC rupture after uneventful cataract surgery is of uncertain etiology. Regardless of the cause, these cases are seen with increasing frequency in my practice (1–4 cases per month), and may be related to patients undergoing cataract surgery at a younger age. Coupled with an increased average life expectancy, there is a longer runway for patients to suffer such complications. Corrective surgery is required when patients present with suboptimal vision due to the IOL being malpositioned, or when sight-threatening complications arise. These complications are more common when vitreous has prolapsed into the anterior chamber and include cystoid macular edema, raised intraocular pressure and endothelial cell loss. In the situation of a malpositioned IOL due to a late postoperative PC rupture, management depends on the status of the anterior capsular rim. In cases where an anterior capsule rim is present, after thorough management of vitreous in the anterior chamber/vitreous wrapped around the IOL, the IOL is then cut and explanted if it is a 1-piece design, or reused and placed in the ciliary sulcus if it is a 3-piece IOL. Optic capture within the capsular rim is preferred with sulcus placement of a 3-piece IOL. In the situation of a PC rupture with no remnant anterior capsular rim or a dislocated lens–capsular bag complex, my preference is to explant the originally implanted IOL after pars plicata vitrectomy, followed by 4-point scleral-fiÝation of a hydrophobic IOL with four close- looped haptics e.g. Micropure® using Gore-TeÝ CV-8 sutures. In my experience, this provides the best long-term stability and durability. Alternatively, I may opt for IOL repositioning and fiÝation to the sclera to secure a dislocated lensqcapsular bag compleÝ in patients who may benefit from shorter surgery, such as elderly patients with significant systemic comorbidities, or in eyes with very low endothelial cell counts, where IOL explantation and additional manipulation within the eye will likely result in corneal decompensation. This is performed by lassoing the haptic–optic junction of the existing 1-piece or 3-piece open-loop IOL through the capsular bag with 6-0 polypropylene Prolene® sutures and securing the suture ends intrasclerally by yange creation.1 Reference £. Assia EI, Wong 8 . Adustable È-0 polypropylene yanged techniµue for scleral fiÝation. Part Ó\ Repositioning of subluxated intraocular lenses. J Cataract Refract Surg. 2020 Oct;46(10):1392-1396. Editors’ note: Dr. 7ong disclosed no relevant financial interest. John WONG, MD Consultant Ophthalmologist, ational ealthcare Group, Eye Institute, Tan Tock Seng Hospital, Singapore 11 Jln Tan Tock Seng, Singapore 308433 drjohnwong@yahoo.com.sg ASIA-PACIFIC PERSPECTIVES zonules, he said it’s a good idea to place a capsular tension ring, which could give something to lasso onto later should it dislocate. Dr. Safran said he’ll place a capsular tension segment and suture to the sclera if things seem loose at the time of surgery. “I’ll do that if I think it’s likely the patient will have a dislocation in their lifetime,” he said, adding, however, that if the patient’s expected lifespan isn’t long or if they’re not that active,
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