10 EyeWorld Asia-Pacific | March 2025 About the Physicians Abhay Vasavada, MS, FRCS (England) | Raghudeep Eye Hospital, Ahmedabad, Jaipur, India | icirc@abhayvasavada.com Reference 1. Culp C, Qu P, Jones J, Fram N, Ogawa G, Masket S, Mamalis N, Werner L. Clinical and histopathological findings in the dead bag syndrome. J Cataract Refract Surg 2022;48(2):177-184. doi: 10.1097/j.jcrs.0000000000000742. 2. Yamane S et al. Flanged Intrascleral Intraocular Lens Fixation with Double – Needle Technique, Ophthalmology, 2017;124:1136–1142. 3. Sumioka T, Werner L, Yasuda S, Okada Y, Mamalis N, Ishikawa N, Saika S. Immunohistochemical findings of lens capsules obtained from dead bag syndrome patients. J Cataract Refract Surg 2024;50(8):862-867. doi: 10.1097/j.jcrs.0000000000001472. 4. FROM THE EDITOR - The dead bag syndrome, Liliana Werner, MD, PhD, Copyright © 2022 Published by Wolters Kluwer on behalf of ASCRS and ESCRS Published by Wolters Kluwer Health, Inc. 0886-3350/$ - see frontmatter https://doi.org/10.1097/j.jcrs.0000000000000930 Relevant Disclosures Vasavada: None IOL material / design remains uncertain with this sample size but warrants further exploration. Only one patient had pseudoexfoliation. Surgery remains the only option. The good news is that there are many options including iris claw lens, refixation / transscleral fixation of the IOL using prolene or Gore-Tex sutures, or exchange of the IOLs using intrascleral fixation with Glued or Yamane technique. Whatever option the surgeon decides, the role of vitrectomy remains indispensable. Working with retinal colleagues is mandatory, in my opinion. Our preference has been the Yamane technique2. The key is to mark the appropriate meridian in the precise way and also mark the distance from the limbus, for penetration of 30 Gauge thin walled needle. It is important to look for Soemmering’s Ring located in the capsular fornices. We detected moderate to extensive degree of Soemmering’s ring in 72% of eyes. This is a result of epithelial mesenchymal transformation (EMT) of the LE Cells located at equator of the capsular bag. Therefore, in the language of Cell biologists, the cells are active and not dead. Histopathological examination reveals split/delaminated capsules and importantly, scanty to no LE cells at the equatorial region of the bag1,3,4. The split capsule is an attempt by remaining LE cells to synthesize and support the frail capsule, also known as pseudo capsule. The million dollar question is: why does it develop only in very few patients, and several years after the primary cataract surgery? For this, we carried out whole exome sequencing in 27 patients. We studied two groups of genes for gene variants: one responsible for survival of the LE cells, and others responsible for the integrity and health of the posterior capsule. We found 6 variants showing remarkably significant higher odds ratios in dead bag cases, in genes responsible for LE cell survival compared to controls with healthy eyes. When we looked into the group of gene variants responsible for posterior capsule integrity, we found 28 variants. So we believe that these genetic variants found in our study could predispose LE cells to undergo programmed cell death, known as apoptosis, and predispose posterior capsules to lose their integrity over a period of time. Whether vitreous plays any role in making the posterior capsule frail remains speculative. But, what does all of this mean to our patients and to us? For our patients, we realize that sudden visual impairment at such a late stage in their life is very impactful as they depend very much on the visual function at that critical phase of their life. For us, the clinicians, we need to emphasize to the patient the importance of remaining under the follow up for his / her lifetime. It is very important that the clinicians and the scientists continue their endeavor together so that spontaneous posterior capsule rupture and the dead bag syndrome no longer remain an enigma. Hopefully, we should be able to predict this event in future and be prepared to change the IOL strategy for implantation. FEATURE
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