7 EyeWorld Asia-Pacific | March 2025 FEATURE Figure 3: Illustration depicts different patterns of lens malposition in Dead Bag Syndrome. Left panel shows the intact lens capsular bag with IOL in situ. The right side top panel shows decentration of IOL inside the bag, the middle panel shows partial dislocation of IOL and the bottom panel shows the complete dislocation of IOL. Source: Abhay Vasavada, MD Figure 4: Posterior capsule rupture with intact anterior capsulorhexis, stable bag in situ and decentered IOL. Source: Abhay Vasavada, MD Figure 5: (Left) Posterior capsule rupture (PCR) with intact capsulorhexis and significant decentration of a single-piece hydrophobic acrylic intraocular lens (IOL). (Right) Fellow eye of the same patient showing a PCR with clear capsular bag and stable, in the bag three-piece hydrophobic acrylic IOL. Source: Abhay Vasavada, MD In contrast, in eyes with zonulopathy, the entire bag containing the IOL gets displaced. Dr. Liliana Werner and the team at Moran Eye Centre showed on histopathological evaluation that there are scanty to no Lens Epithelial (LE) cells at the germinative zone located at the equator of the capsule bag and found a diaphanous frail capsule. There isn’t much information in the literature about the clinical features, risk factors and outcomes following surgical management in cases with the dead bag syndrome. We reported clinical features and risk factors of Dead Bag syndrome (in press, American Journal of Ophthalmology). From June 2021 to July 2024 we had seen 88 eyes with late decentration of IOLs of which 50 Eyes (57%) had confirmed diagnosis of Dead Bag syndrome. In 58% of these eyes, the entire or part of the IOL was inside the bag. In 30% of the eyes, entire IOL was found dislocated into the vitreous. Seven patients in our series had bilateral spontaneous posterior capsule rupture (PCR), yet four of these had an IOL decentration only in one eye with stable IOL in the fellow eye. (Figure 5). Thus, the dead bag syndrome is a disease with a spectrum of clinical manifestations, ranging from spontaneous PCR with a stable IOL, to IOL decentration within the bag, segmental zonulolysis and even total dislocation of the IOL. The mean age at the time of IOL exchange surgery was 67 years. In the majority, the decentration occurred between 11 to 20 years post-primary cataract surgery. A glaring finding from our study is the significant male preponderance. 93% of the eyes belonged to male patients. Another risk factor associated with the dead bag syndrome was axial myopia. 52% of eyes had an axial length (AL) of ≥ 24 mm. It was interesting that no patient had axial length < 22.5 mm. Other studies have reported myopia to be an important predisposing factor for late bag decentration, resulting from zonular weakness. However, the association of myopia with the dead bag syndrome was not well known. The presence of a variety of IOL materials including hydrophobic, hydrophilic and PMMA have been reported in eyes with dead bag syndrome. In our series, 70% were hydrophobic IOLs while the rest were hydrophilic and PMMA. Hydrophobic acrylic IOL has been used more commonly in our hospital as well as in the country during the early 2000s. The association of
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