Early-onset dead bag syndrome following cataract surgery: a case report with clinical and histopathological findings

Abstract

Background

In the present study, we aimed to comprehensively describe the full clinical course of dead bag syndrome (DBS) presenting 17 months after cataract surgery, and to elucidate its clinical characteristics, histopathological features.

Case presentation

A 55-year-old man presented with progressive blurred vision in his left eye 17 months following an uncomplicated cataract extraction. Ophthalmic examination revealed a lax, translucent capsular bag accompanied by partial dislocation of the intraocular lens (IOL)–capsular bag complex. Histopathological analysis showed extensive depletion of lens epithelial cells (LECs), multilayer delamination of the capsular bag, and markedly reduced fibronectin expression. The patient subsequently underwent removal of the displaced IOL and scleral-sutured implantation of a new IOL, which led to substantial postoperative visual recovery.

Conclusion

This case indicated that DBS could manifest within a relatively short postoperative interval. Histopathological analysis showed structural alterations of the capsular bag consistent with DBS following cataract surgery. Accordingly, DBS should be recognized as a potential complication and carefully considered during routine postoperative surveillance following cataract surgery.

Introduction

Phacoemulsification with intraocular lens (IOL) implantation remains the gold-standard surgical approach for the management of cataract. Postoperative IOL dislocation is a recognized complication, with well-established predisposing factors including high myopia, pseudoexfoliation syndrome, uveitis, ocular trauma, and a history of vitrectomy [1–3]. Dead bag syndrome (DBS), first characterized by Samuel Masket and colleagues in 2018 [4], represents a distinct pathological entity associated with late instability of the capsular bag–IOL complex. Previous reports indicate that the mean interval between primary cataract surgery and DBS onset is approximately 9.25 ± 4.79 years [5]. In contrast, the present report described a patient who developed DBS as early as 17 months after cataract surgery. This unusually early presentation suggested that the temporal spectrum of DBS might be broader than previously appreciated and underscored the importance of maintaining clinical vigilance for this condition even during relatively early postoperative follow-up.

Case report

A 55-year-old man presented to the Eye Center of the Second Affiliated Hospital of Zhejiang University School of Medicine with a 1-month history of unexplained blurred vision in his left eye. His ocular history was notable for uneventful cataract surgery in the same eye performed 17 months earlier. At presentation, best-corrected visual acuity (BCVA) in the left eye was 20/66 (0.52 logMAR), and intraocular pressure (IOP) measured by Goldmann applanation tonometry (Suzhou City, Jiangsu Province, China) was 16.5 mmHg. Anterior segment slit-lamp examination (SL-D8Z; Topcon Corporation, Tokyo, Japan) prior to the initial surgery demonstrated an age-related cataract in the left eye, graded as C3N2P1 according to the LOCS II classification (Fig. 1). Ocular biometry (Carl Zeiss Meditec, Jena, Germany) revealed an axial length of 25.96 mm. The original cataract procedure, phacoemulsification with posterior chamber IOL implantation, was performed by author WX using the Stellaris system (Bausch & Lomb Laboratories, Rochester, NY, USA). A TECNIS ZCB00 IOL (Johnson & Johnson Surgical Vision, USA) was implanted in the capsular bag. During surgery, limited posterior capsule polishing was gently applied only within the visual axis using an irrigation/aspiration handpiece. No posterior capsule rupture or other intraoperative complications occurred. One week after surgery, BCVA in the left eye improved to 20/20 (0.0 logMAR).

Fig. 1.

Preoperative evaluation of the left eye (1 month prior to cataract surgery). A Anterior segment photograph demonstrating lens opacity within the visual axis. B AS-OCT showing the lens in a normal position without evidence of displacement

Seventeen months postoperatively, the patient again noted blurred vision in the left eye and returned to the outpatient clinic 2 days later. At that visit, BCVA was 20/22 (0.05 logMAR), while IOP was markedly elevated at 29.8 mmHg. Slit-lamp examination demonstrated noticeable IOL phacodonesis. Following pharmacologic pupil dilation, partial temporal displacement of the IOL–capsular bag complex was identified. Although the posterior capsule remained intact, the capsular bag appeared lax, wrinkled, thin, and unusually transparent (Fig. 2A). Anterior segment optical coherence tomography (AS-OCT; TowardPi Medical Technology Ltd., Beijing, China) corroborated the presence of a markedly loosened capsular bag and temporal deviation of the IOL–capsular bag complex (Fig. 2B). Funduscopic examination revealed a mildly hyperemic optic disc with a cup-to-disc ratio of approximately 0.4. Based on the constellation of clinical findings, a diagnosis of DBS was established.

Fig. 2.

Evaluation of the left eye 17 months after cataract surgery. A: Anterior segment photograph demonstrating temporal displacement of the IOL–capsular bag complex, with the capsular bag appearing lax and transparent. B: AS-OCT confirming IOL–capsular bag dislocation, a loosened capsular bag (blue arrow), and prolapse of vitreous into the anterior chamber (yellow arrow)

Further history-taking disclosed a background of urticaria. The patient denied any ocular trauma, habitual eye rubbing, or prolonged prone positioning. He did, however, report long-term self-administration of two traditional Chinese herbal medicines, Gentiana scabra and Millettia reticulata, for general health maintenance. In view of the elevated IOP, topical antiglaucoma therapy was initiated in the left eye, consisting of carteolol hydrochloride eye drops (Otsuka Pharmaceutical Co., China) twice daily, brinzolamide eye drops (Azopt; Alcon Laboratories, Inc.) three times daily, and brimonidine tartrate eye drops (Alphagan; Allergan Pharmaceuticals, Ireland) three times daily.

Two weeks later, IOP in the left eye was reduced and maintained at 21.0 mmHg. Despite adequate IOP control, progressive temporal displacement of the IOL–capsular bag complex was observed during this interval, accompanied by a decline in uncorrected visual acuity to 20/40 (0.3 logMAR). In view of the ongoing dislocation and visual deterioration, surgical intervention was undertaken under local anesthesia. The procedure comprised removal of the dislocated IOL–capsular bag complex, scleral-sutured fixation of a secondary IOL and anterior vitrectomy. An Akreos Adapt AO IOL (Bausch & Lomb Laboratories, Rochester, NY, USA) was implanted.

Intraoperatively, the excised capsular bag was noted to be strikingly transparent, with no appreciable Soemmerring’s ring formation. The removed capsular tissue was submitted for histopathological evaluation. Given the preoperative evidence of IOL–capsular complex subluxation, we specifically focused histopathological examination on the equatorial region of the excised capsular bag. The excised specimen consisted of the entire capsular bag, but due to extensive delamination and tissue laxity, the boundary between the anterior and posterior capsule components could not be reliably distinguished on histological sections. Histopathological evaluation of the equatorial capsular tissue demonstrated morphological characteristics consistent with DBS. Hematoxylin–eosin (H&E) staining demonstrated a near-complete loss of lens epithelial cells (LECs) together with pronounced multilayer stratification of the capsular membrane (Fig. 4A). Masson trichrome staining revealed a markedly thinned collagen framework with conspicuous vacuolization (Fig. 4B). Immunohistochemical staining for collagen type IV, a principal component of the basement membrane, exhibited weak positivity (Fig. 4C). Regarding fibronectin, a key mediator of postoperative capsular wound healing, immunohistochemical staining was markedly reduced, exhibiting weak and sparse signals with only focal positivity (Fig. 4D). All immunohistochemical assessments were qualitative only, and no quantitative analysis was performed.

Fig. 4.

Histopathological analysis of the equatorial capsular bag from the DBS patient. A: H&E staining demonstrating sparse LECs (triangle) alongside capsular delamination and splitting (arrow). B: Masson’s trichrome staining revealing thin collagen fibers with vacuolization (arrow). C: Collagen type IV immunostaining highlighting the preserved basement membrane component, with positive staining throughout the capsule. D: Fibronectin immunostaining showing only focal, weak positivity within the capsular tissue

For comparative purposes, an anterior capsule specimen was obtained from a 45-year-old male undergoing routine cataract surgery and processed in parallel with the DBS capsular bag for histopathological analysis. Both specimens underwent identical preparation protocols, including fixation, embedding, sectioning at matched thicknesses, and staining with the same reagents and antibody batches under strictly standardized conditions. In histopathological examination, the control anterior capsule displayed a dense, continuous monolayer of morphologically intact LECs (Fig. 5). Notably, the control tissue lacked the pathological features observed in the DBS sample, including pronounced cellular depletion, extracellular matrix disorganization, vacuolization, and capsular stratification. However, it should be noted that due to inherent differences in tissue origin and surgical context, the specimens were not strictly matched; accordingly, the histochemical and immunohistochemical staining of the control was presented as an illustrative reference rather than for quantitative analysis.

Fig. 5.

Histopathological analysis of the anterior capsule from a routine cataract surgery patient. A: H&E staining demonstrating a dense, continuous layer of LECs (triangle) within the capsule. B: Masson’s trichrome staining showing positive collagen staining in the anterior capsular tissue. C: Collagen type IV immunostaining confirming the presence of this basement membrane component throughout the capsule. D: Fibronectin immunostaining revealing weak positivity localized to the inner surface of the anterior capsule

At the 1-month postoperative follow-up, BCVA in the left eye had recovered to 20/20 (0.0 logMAR), IOP was stable at 22.0 mmHg, and the scleral-fixated IOL was well centered in a horizontal position (Fig. 3).

Fig. 3.

Postoperative evaluation of the left eye 1 month after scleral-sutured IOL fixation. A: Anterior segment photograph showing the IOL well-centered within the pupillary zone. B: AS-OCT confirming a horizontally aligned IOL with stable positioning, without tilt or decentration

Discussion and conclusion

As a recently recognized and rare risk factor for IOL dislocation following cataract surgery, the pathogenesis of DBS remains incompletely elucidated. Clinically, DBS is distinguished by pronounced capsular bag laxity, leading to suboptimal IOL centration and frequently accompanied by spontaneous posterior capsule rupture. The capsular bag may present as either centered or decentered; it is typically highly transparent, markedly compliant, and notably lacks both Soemmerring’s ring and Elschnig’s pearls. Histopathological analyses consistently demonstrate a profound depletion or complete absence of LECs within the capsular tissue, together with structural derangements including vacuolization, multilayered stratification, and capsular membrane splitting [4, 6]. These observations stand in stark contrast to the well-established postoperative response, in which residual LECs ordinarily undergo proliferation and migration [7]. Within this canonical wound-healing cascade, fibronectin serves as a critical mediator, accumulating around residual LECs and facilitating activation of transforming growth factor-β signaling (TGF-β), which in turn promotes myofibroblast differentiation and lens fiber cell proliferation, ultimately culminating in the formation of Elschnig’s pearls and Soemmerring’s rings [8, 9].

In the present case, the excised capsular bag exhibited striking transparency. H&E staining revealed only sparse residual LECs accompanied by pronounced capsular stratification (Fig. 4), in sharp contrast to the preserved epithelial monolayer or intact acellular matrix typically observed in postoperative capsules (Fig. 5). It should be noted that the control specimens consisted of anterior capsule samples obtained during routine cataract surgery and were not strictly matched with respect to anatomical origin or surgical history. Moreover, blinding was not feasible given the overt morphological distinctions between the DBS specimen and the controls.

Although DBS is generally considered a late postoperative complication, the present case manifested during the early postoperative period. Preoperative slit-lamp biomicroscopy and AS-OCT demonstrated marked decentration of the capsular bag, while histopathological evaluation further revealed capsular delamination. The mechanisms driving the initiation and progression of capsular splitting following cataract surgery remain to be elucidated and warrant further investigation.

With respect to potential risk factors for DBS, Vandana Nath et al. [10] have identified male sex and axial myopia as significant associations, findings that are consistent with the demographic and biometric characteristics of our patient. One pathogenic hypothesis proposed by Club et al. [4] suggests that white, intumescent cataracts may precipitate LEC death through increased intralenticular osmotic pressure. However, in the present case, the cataract was limited to a cortical opacity within the visual axis and had not progressed to a mature white cataract, rendering this mechanism less likely. Another unresolved issue concerns the potential role of posterior capsule polishing in LEC depletion [4]. During the initial surgery in our patient, posterior capsule polishing was performed gently and confined to the visual axis, with no manipulation of the anterior capsule or equatorial region. Nevertheless, histopathological analysis revealed only sparse residual LECs throughout the excised capsular tissue. This discrepancy suggested that limited polishing of the visual axis alone was unlikely to account for the extensive loss of LECs observed in DBS.

IOL material may also influence clinical outcomes. In this case, a hydrophobic acrylic IOL was implanted during the primary cataract procedure. Consistently, Vandana Nath et al. [10] have reported that the majority of IOLs initially implanted in DBS cases are hydrophobic acrylic. Conversely, Yehezkeli et al. [11] have described spontaneous posterior capsule rupture with IOL decentration occurring 17–20 years after implantation of hydrophilic acrylic IOLs, likewise in the setting of a highly transparent capsular bag. These observations suggest that DBS-like changes are not exclusive to a single IOL material. Whether DBS is mechanistically related to the hydrophobic properties of IOLs therefore remains uncertain and warrants further investigation, although careful long-term surveillance following implantation of hydrophobic acrylic IOLs may still be advisable.

Beyond local anatomical and surgical considerations, systemic inflammatory conditions may also contribute to the pathogenesis of DBS. Patients with atopic dermatitis, for example, exhibit a higher incidence of early-onset cataract and subsequent IOL dislocation [12–14]. One proposed mechanism implicates eosinophil-derived major basic protein (MBP) in the aqueous humor, which has been shown to exert cytotoxic effects on LECs and zonular fibers [14, 15]. Although our patient did not carry a formal diagnosis of atopic disease, he reported a history of chronic cutaneous inflammation. We therefore suggested that a detailed history of atopic dermatitis and other allergic or inflammatory conditions, such as asthma or allergic rhinitis, be routinely obtained when evaluating patients with suspected DBS or unexplained IOL dislocation.

In previously reported DBS cases, the interval between primary cataract surgery and secondary surgical intervention has generally been prolonged, averaging 9.25 ± 4.79 years in the series reported by Club et al. [4], with the shortest documented interval being 3.7 years. In contrast, the interval in our patient was only 17 months. The mechanisms underlying this unusually rapid progression are likely multifactorial. It remains unclear whether chronic inflammatory skin disease and prolonged self-administration of traditional Chinese herbal medicines contributed to the development of this condition. Collectively, this case highlighted that DBS might manifest relatively early in the postoperative course. Consequently, DBS should be included in the differential diagnosis of IOL dislocation even in the short term after cataract surgery, and careful attention should be paid to IOL positioning and posterior capsular integrity during long-term postoperative follow-up.

Abbreviations

DBS

Dead bag syndrome

IOL

Intraocular lens

LECs

Lens epithelial cells

BCVA

Best-corrected visual acuity

IOP

Intraocular pressure

AS-OCT

Anterior segment optical coherence tomography

H&E

Hematoxylin–eosin

TGF-β

Transforming growth factor-β

MBP

Major basic protein

Author contributions

All authors were involved in the data analysis. YFJ and HLZ did the patient follow-up, collected data and drafted the article. XGH edited images of the patient. ZX reviewed the literature. JJL revised the manuscript. WX and YCL were responsible for diagnosis and treatment of the patient and revised the manuscript. All authors read and approved the final manuscript.

Funding

1. The Zhejiang Province Key Research and Development Program (Grant No. 2023C03090). 2. The Zhejiang Provincial Natural Science Foundation of China (LQ23H120004). 3. The National Natural Science Foundation of China (82401264).

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This case report was approved by the ethics committee of the 2nd Affiliated Hospital, School of Medicine, Zhejiang University (No.2025 − 1793). All procedures adhered to the tenets of the Declaration of Helsinki. Informed consent to participate in the study was obtained from subject. Informed consents for the use of medical data and publication of identifying information/images in an online open-access publication were also obtained from subject. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Written informed consent for publication of his clinical details and clinical images was obtained from the patient. A copy of the consent form is available for review by the Editor of this journal.

Competing interests

The authors declare no competing interests.