Osher: Dead Bag Syndrome won the Blumenthal top prize at
ESCRS, produced
by Doctors Liliana Werner, Jones, Fram, Ogawa, Masket, and Mamalis from the United States.
Mamalis: One of the most important conditions leading
to zonular weakness and subsequent IOL dislocation is
pseudoexfoliation. Capsular contraction and phimosis
are common findings.
Histopathology usually shows fibrous metaplasia
of lens epithelial cells, Soemmering ring formation,
and pseudoexfoliation material on the capsule.
Pseudoexfoliation may be implicated in an even larger
proportion of late in-the-bag eye IOL dislocations than
previously thought as a result
of significant clinical underdiagnosis.
However, there have been different reports
of late postoperative IOL dislocation sharing the common
feature of a very clear bag
many years after surgery.
Sam Masket coined the term "dead bag syndrome" referring
to these cases.
So what exactly is this syndrome?
Clinical and surgical features include no signs
of zonular instability noted
during the implantation surgeries,
which may be completely uneventful. Later postoperatively,
the capsular bag becomes diaphanous and floppy
and unable to support the IOL within it.
There may be initial subluxation of the IOL inside
of the bag, sometimes through a peripheral defect,
while the capsular bag itself is centered. In many cases,
the reason for explantation is in-the-bag IOL dislocation.
There is no association between this syndrome
and a particular IOL design or material.
In this case, the lens was rotated out of the capsular bag
and bisected for explantation.
The remaining capsule was removed.
Note the clarity of the capsular bag without fibrotic
or proliferative changes. After anterior vitrectomy
and vitreal staining with triamcinolone, scleral fixation
of a 3-piece hydrophobic acrylic lens was accomplished
using the Yamane technique.
In this case of initial IOL subluxation,
there was already in-the-bag IOL dislocation into the
anterior chamber at the time of surgery.
The capsular bag is so clear that it is difficult to see it
during bisection of the lens
for explantation.
A 3-piece hydrophobic acrylic lens was also scleral
fixated using the Yamane technique.
Here, a dislocated single-piece lens is removed from the eye
after vitrectomy.
The capsulorrhexis is intact,
and the bag, which is very clear,
still shows good resiliency with appropriate zonular support.
A 3-piece lens was
therefore positioned in the sulcus with capture the optic
through the capsulorrhexis.
In this case, a dislocated 3-piece lens is removed from
the eye after vitrectomy.
The capsule is thin, clear,
and diaphanous without evidence
of appropriate zonular support.
It is therefore removed
through a paracentesis, and a single-piece
PMMA lens is fixated to the sclera with Gore-Tex sutures.
Pathological analysis
of the in-the-bag dislocated lenses shows no fibrotic
changes in the capsular bag
and no proliferative material within it.
The main feature of histopathology is capsular splitting
or delamination.
Its presence in areas of zonular attachment leads
to dislocation.
Lens epithelial cells are rarely seen
or are completely absent from the inner surface of the capsule.
We had the opportunity to evaluate histopathologic findings
of 8 cases of dead bag syndrome
and compare them with 40 cases
of in-the-bag IOL dislocation, including 26 with
and 14 without pseudoexfoliation.
As you can see here, Soemmering ring formation
and lens epithelial cells were present in all 40 cases
of in-the-bag IOL dislocation,
and capsular splitting was seen in only 1 case.
There is also capsular splitting in true
exfoliation syndrome.
However, in this syndrome, there's usually a thin membrane
of the delaminated capsule on the anterior surface
of the crystalline lens before cataract surgery.
This condition is usually associated with chronic exposure
to intense heat or infrared radiation.
The exact etiology of dead bag syndrome is unknown.
Cortical lens fibers
and lens epithelial cells continue
to deposit extracellular matrix
and lens capsule components at their basal ends,
which contributes to the thickening of the capsule
throughout life. There's been a recent emphasis on polishing
techniques to prevent capsular bag opacification,
especially in association with premium lenses.
However, even an extensive polishing cannot completely
remove all lens epithelial cells.
Furthermore, polishing is usually not done at the capsular
bag equator, as this region is not readily visible
and many dead bag cases are not associated
with extensive polishing.
One of us observed cases of white intumescent cataracts
that evolved into dead bag syndrome, suggesting there may be
a role of oncotic pressure within the capsular bag in
killing lens epithelial cells.
However, many dead bag cases are not related to this type
of cataract, so other factors are likely involved.
The capsule is an anchor point for the basal surfaces
of epithelial and fiber cells,
and also provides necessary signals
for proper lens cell proliferation, migration,
and differentiation. In the dead bag syndrome,
another possibility is
that the initial problem is in the capsule itself,
which initiates a cycle of lens epithelial cell damage
with further damage to the capsule.
There are a lot of unknowns in the etiology
of the dead bag syndrome, as well as in its manifestations,
as the findings described here could represent the
severe end of the spectrum.
Management is advised on a case-by-case basis,
as demonstrated in this video.
This condition needs to be further studied.
Yeoh: Congratulations on the 40th anniversary
of the Video Journal of Cataract, Refractive,
and Glaucoma Surgery.
Forty years. It's been a long time,
but Bob Osher was the first to realize that the medium
of filmmaking lent itself exquisitely to cataract
and anterior segment surgery in general.
And these last 40 years,
he has spent compiling wonderful educational videos
for all of us.
And do you know, in the pre-internet days, Bob had
to lug these videotapes to the post office to send them off
to us or bring them along to the annual conferences
where his video symposiums were run
and he would hand them out physically.
Today, of course, with the Internet, we are much more lucky
or much, it's much easier for us to access these videotapes.
So we have no excuse
for not looking at these wonderful educational videos.
So Bob, the world owes you an incredible debt in the
educational efforts you have made. Thank you.
Osher: Thank you, Ron.