The effects of trypan blue use on the corneal endothelium during cataract surgery in patients with pseudoexfoliation syndrome (PEX).

PURPOSE: In the present clinical study, it was aimed to investigate the possible effects of Trypan blue (TB) use on the corneal endothelium during cataract surgery in eyes with pseudoexfoliation syndrome (PEX) during a three-month follow-up period using the contralateral eye control design. METHODS: This prospective, randomised controlled, individual cohort study included 92 eyes of 46 patients with bilateral PEX and cataracts. While 1% TB was applied to one eye of the patients before capsulorhexis (study group), it was not applied to the other eye (control group). Both groups were compared preoperatively and postoperatively in terms of endothelial cell density (ECD), endothelial cell loss (%), pleomorphism, polymegathism and central corneal thickness (CCT) using specular microscopy. RESULTS: Preoperative corneal ECD was measured as 2362.56 ± 253.27 in the study group, 2380.84 ± 220.54 in the control group, and 2145.58 ± 221.71 in the study group and 2184.97 ± 200.94 cells/mm2 in the control group in the postoperative 3rd-month follow-up (p = 0.71 and = 0.37, respectively). In addition, there were no significant differences between the two groups in terms of the percentage of hexagonal cells, coefficient of variation (CV), and CCT both preoperatively and postoperatively 3 months later (p = 0.78, =0.39, =0.95 preoperatively and p = 0.31, =0.26, =0.83 postoperatively, respectively). CONCLUSION: This study demonstrated that the injection of 1% TB into the anterior chamber for staining the anterior capsule during cataract surgery did not cause significant corneal endothelial changes at postoperative 3rd months, despite the increased fragility of corneal endothelial cells in patients with PEX.

Corneal staining during cataract surgery: Natural course, ASOCT features, and preventive measures.

We report the natural course of the accidental injection of trypan blue into the corneal stroma while performing a routine cataract surgery by a resident during a training session. The corneal staining resolved with conservative medical treatment over 7 weeks. This case describes the anterior segment optical coherence tomography (ASOCT) features of corneal staining. It emphasizes on the relatively benign nature of this dye and the follow-up course. Causes that may be responsible for this untoward complication are highlighted with the necessary preventive measures that need to be taken care are also discussed.

Comparison of trypan blue and Brilliant Blue G for staining of the anterior lens capsule during cataract surgery: short-term results.

PURPOSE: The present study aimed to evaluate the potential corneal endothelial cell toxicity of trypan blue (TB) and Brilliant Blue G (BBG), two dyes used to stain the anterior capsule in cataract surgery. METHODS: We conducted a single-center, prospective, randomized study in which 150 eyes of 117 patients were randomly divided into control (CT), TB, and BBG groups. Preoperative and postoperative (1, 3, and 6 months) values for corrected distance visual acuity (CDVA), corneal endothelial cell count, and central corneal thickness were compared among the three groups. RESULTS: A total of 111 eyes from 88 patients were completely analyzed. The CDVA (logarithm of the minimal angle of resolution) values in the CT, TB, and BBG groups 1 month after surgery were 0.001, 0.023, and 0.019, respectively. The corneal endothelial cell counts 6 months after surgery were 2711 ± 225, 2748 ± 251, and 2680 ± 284 cells/mm2, respectively. The central corneal thicknesses 6 months after surgery were 524.3 ± 35.5, 532.2 ± 36.1, and 531.4 ± 33.0 µm, respectively. There were no significant differences in CDVA, endothelial cell count, or central corneal thickness among the three groups during the follow-up period. CONCLUSIONS: Our findings indicate that neither TB nor BBG was associated with detectable toxicity to corneal endothelial cells during cataract surgery, even when injected directly into the anterior chamber. Additionally, BBG exhibited equivalent staining efficiency to TB.

Safety evaluation of subretinal injection of trypan blue in rats.

OBJECTIVE: To determine the appropriate concentration of trypan blue (TB) for subretinal injection in a rat model and to provide a safety profile that limits retinal toxicity while maintaining dye visibility. MATERIALS AND METHODS: Adult rats were subretinally injected with various concentrations of either TB or phosphate-buffered saline (PBS); rats which received sham injections served as an additional control. The injected areas were visualized under a surgical microscope. Electroretinography (ERG) was performed to measure retinal function. Animals were then sacrificed, and the eyes were sectioned and examined by light microscopy. Terminal deoxynucleotidy1 transferase dUTP nick-end labeling (TUNEL) was applied to determine retinal apoptosis. RESULTS: One day after the subretinal injection, TB stains were visible under the surgical microscope in the 0.2%, 0.08%, and 0.04% TB-injected groups, but not in the 0.02% TB-injected group. TB stain was detectable in the retina and sclera of the 0.2%, 0.08%, and 0.04% TB-injected groups for over 2 weeks after injection. However, the amplitudes of ERGa- and b-waves were affected and became significantly lower in the 0.2% TB-injected group than the amplitudes in the PBS-, or sham-injected group. Moreover, TUNEL+ cells appeared in the outer nuclear layer (ONL), ganglion cell layer (GCL), and retinal pigment epithelium (RPE) layer of the 0.2% and 0.08% TB-injected groups at 1 and 7 days after subretinal injection. In contrast, very few TUNEL+ cells were found in the 0.04% TB- or PBS-injected group. Two weeks after injection, the ONL was significantly thinner in the 0.2% TB-injected group than in the 0.04% TB-, PBS- or sham-injected group. CONCLUSIONS: TB injection induces a dose-dependent neurotoxic effect on retinal cells. Subretinal injection of 0.04% TB is relatively safe and effective for subretinal staining.

Transplantation Blues: Inadvertent Staining of Amyloid Deposits With Trypan Blue.

PURPOSE: To describe inadvertent persistent staining of stromal amyloid deposits by trypan blue (TB) after penetrating keratoplasty (PK) and Descemet membrane endothelial keratoplasty (DMEK) performed in patients with corneal amyloidosis. METHODS: Case series of patients with corneal amyloidosis in whom intraoperative TB was used. RESULTS: One patient, hospitalized for acute rejection 6 weeks after DMEK, presented with an intense blue staining of small, spindle-shaped structures in the anterior half of the cornea. DMEK had been performed for endothelial failure of a previous PK procedure done 13 years earlier for advanced lattice corneal dystrophy (LCD). After 6 months, the stromal blue tattoo persisted with impaired visual acuity, and PK was performed. Blue-stained structures were amyloid deposits characteristic of LCD recurrence. In parallel, among 85 consecutive triple procedures (PK + cataract + intraocular lens [IOL]) performed over 7 years, in which TB was used, only patients with LCD (n = 18 eyes in 17 patients) or presumed secondary amyloidosis due to chronic inflammation (n = 1), presented an isolated intense blue ring of the graft-host interface. This persisted up to 7 years with no clinical consequence. CONCLUSIONS: TB can stain corneal amyloid deposits. After PK, staining is limited to the recipient peripheral cornea and has no apparent clinical consequence. However, during DMEK performed after a failed PK, TB stains fibrils accumulated during slow LCD recurrence and scattered on the whole graft. The long-term staining duration indicates strong interactions between TB and amyloid.

Generic trypan blue as possible cause of a cluster of toxic anterior segment syndrome cases after uneventful cataract surgery.

Five of 16 patients having uneventful cataract surgery over 2 consecutive days presented on the first postoperative day with painless, unexpected blurry vision; marked limbus-to-limbus corneal edema; and severe anterior chamber inflammation with hypopyon and fibrin formation. Review of the records showed the 5 patients had received an intracameral injection of generic trypan blue solution 0.06% to facilitate the capsulorhexis. Patients who had not received the trypan blue injection had an uneventful first-day check and subsequent course. Management comprised intense topical steroids and close follow-up, which led to gradual improvement in all cases. The batch of trypan blue vials was withdrawn, and there were no additional cases of toxic anterior segment syndrome (TASS). This TASS cluster highlights a rarely reported cause of the syndrome, underscoring the need for thorough documentation of solutions and/or medications used intraoperatively and surgeon awareness of possible adverse events.

[Rate of visual recovery after macular hole surgery with intraoperative optical coherence tomography and visualization of the internal limiting membrane]. / Tempy vosstanovleniia ostroty zreniia posle khirurgicheskogo lecheniia makuliarnykh razryvov s intraoperatsionnym primeneniem opticheskoi kogerentnoi tomografii i razlichnykh metodov vizualizatsii vnutrennei pogranichnoi membrany.

Currently, multiple techniques exist to repair a macular hole, but the functional result may be largely affected by the use of dyes during surgery. With our original visualization methods, one is able to remove the internal limiting membrane (ILM) without staining, and thus to avoid the toxic effect of dyes. AIM: to compare anatomical and functional results of surgical closure of large macular holes with or without ILM staining. MATERIAL AND METHODS: A total of 160 patients (190 eyes) were divided into 2 groups. Patients from group 1 (60 eyes) were subjected to surgery that involved the use of a dye, while in group 2 (130 eyes) ILM was not performed. Anatomical and functional results of the two groups were then compared. RESULTS: The next day after surgery, a large improvement in the best corrected visual acuity - of 3 lines or more - was found in 28 controls (46.6%) and 98 patients from the main group (75.4%). There was no significant change in 24 and 27 patients, respectively (40.0% and 20.7%). The remaining 8 and 5 patients (13.4% and 3.9%) deteriorated by 3 lines or more. CONCLUSION: Stain-free removal of the ILM under green-yellow light favours rapid recovery of visual acuity in patients with macular holes. Anatomical reconstruction of the foveola, including complete approximation of the hole margins and keeping the defect closed until the end of the operation, is controlled through a built-in optical coherence tomograph ensuring high anatomical and functional results.

Persistent staining of lattice lines after intraoperative trypan blue use in patients with lattice corneal dystrophy.

PURPOSE: The aim of this study was to report the persistent staining of corneal lattice lines resulting from the intraoperative use of trypan blue. METHODS: This is a case series. RESULTS: Four patients with lattice corneal dystrophy (LCD) who underwent either deep anterior lamellar keratoplasty or cataract extraction with intraoperative trypan blue use demonstrated persistent, postoperative trypan staining of lattice lines on slit-lamp examination out to final follow-up (range, 176 to 541 days postoperatively). CONCLUSIONS: This case series demonstrates the previously unreported finding that intraoperative trypan blue stains corneal lattice lines in LCD. Trypan blue staining, localized in previous laboratory studies to amyloid deposits, seems to persist for months or longer and may be permanent in human tissue. Although the staining was not visually significant, animal models suggest a stimulatory effect on progression of amyloidosis. Clinicians should be aware of the potential for permanent corneal staining and possible disease progression with the use of intraoperative trypan blue in patients with LCD.

Quirks of dye nomenclature. 3. Trypan blue.

Trypan blue is colorant from the 19(th) century that has an association with Africa as a chemotherapeutic agent against protozoan (Trypanosomal) infections, which cause sleeping sickness. The dye still is used for staining biopsies, living cells and organisms, and it also has been used as a colorant for textiles.

Safety testing of blue vital dyes using cell culture models.

PURPOSE: To investigate the safety of trypan blue, brilliant blue G (BBG), Evans blue (EB), patent blue, Chicago blue (CB), and bromophenol blue (BB), with and without halogen and xenon light exposure. METHODS: All dyes were diluted in a balanced saline solution at a concentration of 0.5%. Cells of the human RPE line ARPE-19 and rat RGC5 were exposed to vital dyes for 5 min. Experiments with and without xenon or halogen illumination were performed. The viability of ARPE-19 and RGC5 cells was determined at 12, 24, or 120 h by a cell proliferation assay using WST-1 reagent. The apoptotic events as well as cell numbers were registered for 72 h and counted by time-lapse videomicroscopy. RESULTS: There was no evidence of ARPE-19 or RGC5 toxicity, immediate (0 and 24 h) or delayed (120 h), following exclusive exposure to each single dye. After halogen light exposure, ARPE-19 cell lines did not show any significant toxicity, except for when they were exposed to EB. After xenon illumination, ARPE-19 cells showed a marked decrease in cell viability when exposed to EB or CB and a moderate decrease when exposed to BBG and BB. After xenon illumination, RGC5 cells showed the highest decrease in cell viability when exposed to EB and CB; BB caused the same decrease in cell viability as in ARPE-19 cells. CONCLUSION: Interaction of light from endo-illumination source and blue vital dyes may increase the risk of retinal toxicity.

Transient leopard spot corneal endothelial staining with trypan blue during cataract surgery in a child with congenital rubella syndrome.

We report the complication of corneal endothelial staining with trypan blue that limited the surgical view during cataract extraction in a 10-month-old boy. The boy had presented with a pigmentary retinopathy, microphthalmia, and a dense, white, unilateral congenital cataract. He was suspected of having, and was later diagnosed with, congenital rubella syndrome. We hypothesize that the corneal staining may have resulted from virally induced corneal endothelial damage. To our knowledge, this is the first reported case of trypan blue adversely affecting congenital cataract surgery.

Inadvertent trypan blue posterior capsule staining during cataract surgery.

PURPOSE: To report 5 cases of inadvertent posterior capsule staining with trypan blue during phacoemulsification. DESIGN: Retrospective, observational case series. METHODS: Five cases of posterior capsule staining with trypan blue were identified from cataract surgeries performed at an academic institution. All 5 eyes underwent phacoemulsification with use of iris retractors. The surgical videos from each case were reviewed to better understand the mechanisms and risk factors for posterior capsule staining with trypan blue and techniques to avoid this complication. RESULTS: No eyes had clinical evidence of zonular pathology during their preoperative examination. Only 1 patient reported a possible childhood history of trauma to both eyes. One eye had uveitis, requiring posterior synechialysis. All 5 cases involved the use of iris retractors. No other intraoperative complications occurred, and the intraocular lens was successfully placed in the capsular bag in all cases. All eyes had resolution of posterior capsule staining by postoperative day 8. CONCLUSIONS: Inadvertent posterior capsule staining with trypan blue can occur in eyes that appear structurally normal. The use of iris retractors may facilitate posterior capsule staining by allowing the posterior flow of trypan blue under the iris and through the zonules to the posterior capsule. Surgeons should consider techniques to minimize the risk of posterior capsule staining, particularly in cases involving the use of iris retractors.

Unintentional staining of the posterior lens capsule with trypan blue dye during phacoemulsification: case report.

We report a complication related to the use of trypan blue during capsular staining of the anterior lens capsule during phacoemulsification surgery. In phacoemulsification surgery of the left eye, trypan blue was injected using an air bubble technique. Unintentionally, trypan blue was administered under high pressure, dispersing the dye through the zonules leading to staining of the posterior capsule. This caused a temporary disturbance of visual acuity during the postoperative period.