Late Onset Of Spontaneous Posterior Capsule Rupture With Intraocular Lens Dislocation: A Case Report Of Dead Bag Syndrome

To describe the management of a case report with late spontaneous posterior capsule rupture accompanied by intraocular lens (IOL) dislocation, occurring years after uncomplicated cataract surgery, attributed to dead bag syndrome.

Cataract surgery can lead to a rare complication known as dead bag syndrome. This condition is thought to result from the gradual loss of epithelial cells within the lens capsule, causing it to become more diaphanous and floppy over time, potentially leading to late dislocation of the intraocular lens (IOL) years after uncomplicated cataract surgery. This syndrome can be related to spontaneous posterior capsule rupture after minor trauma due to the increased fragility of the posterior capsule.

A 70-year-old patient presented with a one-week history of vision loss in the left eye (OS). The patient had undergone cataract surgery fifteen years ago, during which single-piece hydrophobic acrylic intraocular lenses (IOLs) were implanted in both eyes without any complications. The patient remained asymptomatic with no visual changes until present. History of trauma, high myopia, or connective tissue disorders was denied. Visual acuity was 20/25 in the right eye (OD) and counting fingers at 2 meters in the OS. Anterior segment slit lamp examination of the OD revealed vitreous near the pupillary margin, a partially subluxated intraocular lens, and posterior capsule rupture with lens sac folds. In the OS, there was a superior subluxation of the IOL/lens capsule complex and a dislocation of the IOL into the anterior vitreous cavity, accompanied by posterior capsule rupture and lens sac folds. In both eyes, the posterior capsules appeared clear, without any indications of posterior capsule opacification, fibrosis, pseudoexfoliation, or prior YAG laser treatment. The intraocular pressure measured 34/32 mmHg. Hypotensive treatment was initiated in both eyes. Intraocular lens extraction, pars plana vitrectomy, and scleral-fixated Carlevale IOL implantation were performed in the OS. In the 1-month postoperative visit, the patient achieved uncorrected 20/25 vision. The OD continues to be under observation.

Spontaneous posterior capsule rupture, a rare complication of cataract surgery, can be related to dead bag syndrome, a recently identified condition thought to be caused by the loss of epithelial cells, resulting in the lens capsule becoming floppy and fragile. In our case, management of the right eye consisted on observation due to the minimum luxation and good visual acuity. The left eye, which presented a significant IOL subluxation, required removal of the IOL/lens capsule complex with secondary scleral-fixated IOL implantation. There is insufficient evidence regarding the exact mechanism underlying this late complication. Further investigation is necessary to understand its pathogenesis and develop effective prevention methods.