Dead bag syndrome may present bilaterally but asymmetrically years following uncomplicated cataract surgery, including in patients without recognized risk factors for late intraocular lens instability.
Researchers described a healthy 69-year-old man who presented with sudden, painless decreased vision in the left eye for 2 weeks. He had undergone uncomplicated phacoemulsification with posterior chamber intraocular lens (IOL) implantation in the right eye in 2017 and the left eye in 2019. He had no history of ocular trauma, and examination showed no signs of pseudoexfoliation. Other recognized risk factors, including uveitis and systemic connective tissue disorders, were also absent.
Clinical evaluation showed uncorrected visual acuity of 20/25 in the right eye and 20/300 in the left eye. Both eyes had central posterior capsular rupture (PCR) and vitreous prolapse into the anterior chamber. However, the IOL remained in place in the right eye, whereas the patient was aphakic in the left eye, with a dislocated IOL confirmed by B-scan ultrasound. Dilated examination showed a flat retina without retinal detachment in the right eye and a healthy, flat retina in the left eye. The bilateral spontaneous PCR was considered clinically consistent with dead bag syndrome (DBS).
The patient underwent pars plana vitrectomy with removal of the dislocated IOL and secondary implantation of a scleral-fixated 3-piece IOL in the left eye. At 1 month, uncorrected visual acuity improved from 20/300 to 20/20, and the secondary IOL was well centered.
The right eye was managed with observation. Despite central PCR and vitreous prolapse, the IOL remained stable, and the patient remained asymptomatic, with 20/20 visual acuity at follow-up. The researchers therefore elected not to intervene in that eye.
DBS is a rare late complication of cataract surgery characterized by progressive degeneration of the capsular bag, the researchers noted. Degeneration may involve loss of lens epithelial cells and structural weakening and thinning of the posterior capsule, creating susceptibility to IOL instability and spontaneous PCR. The researchers noted that DBS does not directly cause PCR but predisposes the capsule to rupture under minimal mechanical stress or spontaneously. The full case report is available in the International Medical Case Reports Journal.
Although bilateral DBS has been documented previously, the researchers considered this case unusual because the patient was systemically healthy and developed spontaneous PCR in both eyes with asymmetric symptoms. They noted that the idiopathic, bilateral presentation could point to an individual predisposition or unidentified underlying factors, although these possibilities remain poorly understood.
The report was limited by its single-patient design, which limits causal conclusions or generalization to a broader population. In addition, the diagnosis of DBS was based on clinical findings because histopathologic confirmation of the capsular bag was not obtained.
The case suggests that DBS may warrant consideration as a rare differential diagnosis for late spontaneous PCR following uncomplicated cataract surgery, even when recognized risk factors are absent. In this patient, management tailored to the different presentations in each eye resulted in 20/20 visual acuity in both eyes at follow-up.
“Despite significant structural complications, excellent visual outcomes can be achieved through careful clinical assessment and tailored surgical intervention,” wrote Shahad Alruwaili, of King Khaled Eye Specialist Hospital and Research Center, and colleagues.
The authors reported no conflicts of interest.
