Clinical Features, Phenotypic Spectrum, and Associated Factors in Histopathologically Confirmed Dead Bag Syndrome

PURPOSE: To characterize the demographic, ocular, systemic, and histopathologic features of patients undergoing surgery for late intraocular lens (IOL) instability with clinically suspected dead bag syndrome (DBS). SETTING: Private ophthalmology practice and tertiary ophthalmic pathology laboratory. DESIGN: Single-center consecutive case series with prospective tissue collection and retrospective chart review. METHODS: Capsular bag remnants were explanted during secondary IOL surgery and submitted for histopathologic examination. Demographic, ocular, and systemic characteristics were obtained from the medical record. Lens epithelial cell (LEC) status was graded as 0 = absent; 1 = rare residual LECs; 2 = focal identifiable LEC segments. Specimens were assessed for capsular splitting/schisis, cortical material, and anterior capsular fibrous metaplasia. Exploratory clinical comparisons were performed between LEC grade 0 and LEC grade 1-2 subgroups. RESULTS: Thirty-one eyes from 26 patients underwent secondary IOL surgery for late IOL subluxation or dislocation with clinical suspicion of DBS, including 27 with histopathologic evaluation. Mean age at secondary surgery was 70.5 ± 10.5 years and 80.7% patients were male. Median time from cataract surgery to presentation was 13.0 years (IQR 9.0-16.5). Axial myopia was present in 6/31 eyes (19.4%). Atopy was documented in 9/31 (29.0%), prior radiation or chemotherapy exposure in 8/31 (25.8%), autoimmune disease in 10/31 (32.3%), and ACE inhibitor or ARB use in 14/31 (45.2%). Complete LEC absence (grade 0) was present in 8/27 (29.6%), while 19/27 (70.4%) demonstrated residual LECs and/or cortical material (grades 1-2). Spontaneous posterior capsular rupture was documented in 15/31 (48.4%) cases and in 15/27 (55.6%) histopathology-confirmed cases. Atopy was more frequent in LEC grade 0 than among LEC grade 1-2 eyes (37.5% vs 15.8%; P = 0.32), though this did not reach statistical significance. CONCLUSIONS: DBS represents a histopathologically definable spectrum of capsular degeneration characterized by LEC depletion and capsular splitting with structural failure leading to late IOL instability. Nearly half of confirmed cases presented without clinically evident spontaneous posterior capsular rupture, suggesting that rupture is not required for DBS diagnosis.