Farbstoffe

Brilliant Peel / Brilliant Blue G

Henrich PB, Valmaggia C, Lang C, Cattin PC:

THE PRICE FOR REDUCED LIGHT TOXICITY: DO ENDOILLUMINATOR SPECTRAL FILTERS DECREASE COLOR CONTRAST DURING BRILLIANT BLUE G-ASSISTED CHROMOVITRECTOMY?

Graefes Arch Clin Exp Ophthalmol 2014;252(3):367-74.

Background
Vitreoretinal surgeons have been slow to adopt the use of spectral filters for endoillumination to reduce retinal light toxicity. This study shows that spectral filters can be used without a loss in color contrast during brilliant blue G chromovitrectomy.

Methods
To evaluate the influence of intra operative spectral light filters on perceivable contrast during Brilliant Blue G chromovitrectomy, a prospective, observational clinical study was carried out on 59 consecutive Brilliant Blue G chromovitrectomy interventions in 59 patients admitted for macular holes, macular pucker or vitreomacular traction syndromes. Subsequent to peeling of the internal limiting membrane, six different illumination modes were enabled consecutively: mercury vapor, mercury vapor/xenon, and xenon followed by xenon combined with an amber, green or yellow spectral filter. Main outcome measure was the chromaticity spread between stained internal limiting membrane and unstained retina as a measure for the color contrast perceived by the human eye.

Results
Mean chromaticity scores were similar for all light sources: mercury vapor 7.97, mercury vapor/xenon 7.96 (p = 0.96), and xenon 7.41 (p = 0.55). Compared to xenon, the additional use of endoillumination spectral filters did not change contrast recognizability: Chromaticity scores were 9.38 for the amber filter (p = 0.13), 6.63 for the green and 7.02 for the yellow filter (p = 0.37 and 0.64, respectively). When comparing the different filters head-to-head, the amber filter was superior to the green filter (p = 0.03), while the yellow was intermediate and not significantly different from either the amber (p = 0.08) or the green filter (p = 0.51).

Conclusions
Color contrast perceptibility during Brilliant Blue G assisted chromovitrectomy is similar with mercury vapor, mercury vapor/xenon or xenon light sources. Spectral filters do not decrease color contrast recognizability. Head-to-head comparison shows a significant advantage for the amber over the green filter with respect to contrast generation, the yellow filter is intermediate. As spectral filters are known to greatly reduce retinal light toxicity, we suggest donor eye studies to validate whether the amber filter should be generally recommended for Brilliant Blue G chromovitrectomy.

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Williamson TH, Lee E:

IDIOPATHIC MACULAR HOLE: ANALYSIS OF VISUAL OUTCOMES AND THE USE OF INDOCYANINE GREEN OR BRILLIANT BLUE FOR INTERNAL LIMITING MEMBRANE PEEL.

Graefes Arch Clin Exp Ophthalmol 2014;252(3):395-400.

BACKGROUND:
Our aim was to analyze outcomes of idiopathic macular hole surgeries in relation to staging and the use of indocyanine green (ICG) or brilliant blue (BB) for internal limiting membrane (ILM) peel.

METHODS:
Baseline, surgical, and outcome data for 351 consecutive primary macular hole surgeries was prospectively collected using electronic medical record software between 2001 and 2011. The outcomes for these cases were analysed in relation to staging and the use of ICG (0.5 mg/ml) or BB for ILM peel.

CONCLUSIONS:
Macular hole stage is a useful measure to help predict the chance of postoperative hole closure and visual outcome. The relationship between duration of symptoms and increasing stage suggests macula hole patients require prompt referral for consideration of early surgery. Better visual outcomes were achieved with BB for ILM peel than with ICG.

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Henrich PB, Valmaggia C, Lang C, Priglinger SG, Haritoglou C, Strauss RW, Cattin PC:

CONTRAST RECOGNIZABILITY DURING BRILLIANT BLUE G - AND HEAVIER-THAN-WATER BRILLIANT BLUE G-ASSISTED CHROMOVITRECTOMY: A QUANTITATIVE ANALYSIS.

Acta Ophthalmol 2013;91(2):e120-4.

PURPOSE:
To evaluate the potential of heavier-than-water brilliant blue G (BBG-D(2) 0) to stain the internal limiting membrane (ILM) during chromovitrectomy.

METHODS:
In a nonrandomized, prospective, clinical multicentre study, 71 consecutive chromovitrectomy interventions in 71 patients were analysed. During routine 23-gauge vitrectomy, conventional 0.25 mg/ml BBG was employed in 21 and 0.25 mg/ml BBG-D(2) 0 in 50 patients. All interventions were videotaped. Post-operatively, video frames were viewed and dye performance assessed subjectively and objectively. Main outcome measure was the chromaticity difference between the stained ILM and the unstained underlying retina, measured by means of an objective and quantitative analysis method to describe colour contrast strengths as they are perceived by the human eye.

RESULTS:
Removal of the ILM was possible in all interventions without additional vital dyes. BBG-D(2) 0 readily sank to the retinal surface, while conventional BBG tended to swirl up throughout the vitreous cavity. Conventional BBG was removed either with active suction or with a flute needle. Brilliant blue G-D(2) 0 needed to be whirled up from the retinal surface with a flute needle before aspiration. Objective chromaticity measurements yielded a mean chromaticity score of 7.98 for BBG-D(2) 0 and 6.51 for BBG (p = 0.09).

CONCLUSIONS:
Brilliant blue G-D(2) 0 readily sinks to the retinal surface after injection and can be conveniently removed with a flute needle or active suction during chromovitrectomy. Based on the premises of the chromaticity measurements in this study, BBG's ILM staining capacity was not significantly improved through the recent revision its preparation, although a tendency towards slightly improved contrasts between the ILM and the underlying retina was observed.

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Maier MM, Rass S, Mueller C, Feucht N, Lohmann CP:

TRANSCONJUNCTIVAL SUTURELESS PARS PLANA VITRECTOMY AND BRILLIANT PEEL (BP)-ASSISTED ILM PEELING IN PATIENTS WITH MACULAR HOLES

Klin Monbl Augenheilkd 2013;230(7):701-6

PURPOSE:
The aim of this study was to evaluate the visual and anatomic outcome after 23-gauge transconjunctival sutureless pars plana vitrectomy and Brilliant Peel (BP)-assisted ILM peeling in patients with macular holes.

METHODS:
In a consecutive retrospective study in 41 eyes of 41 patients with macular holes a standardised 23-G transconjunctival sutureless pars plana vitrectomy with ILM-peeling and gas tamponade was performed. All patients underwent preoperative measurements of visual acuity (VA), the maximum hole diameter, basis, height, and intraretinal changes using high resolution optical coherence tomography (SD-OCT; Spectralis; Heidelberg Engineering). Main outcome measures included visual acuity 1, 3, and 6 months after surgery and the closure rate. We also evaluated photoreceptor inner/outer segment (IS/OS) integrity as seen in SD-OCT for correlation with visual outcomes after macular hole surgery.

RESULTS:
At baseline the mean best corrected visual acuity (BCVA) was 0.2 (0.77 logMAR). BCVA improved significantly to 0.4 (0.46 logMAR) after 1 month, to 0.44 (0.41 logMAR) after 3 months and to 0.58 (0.28 logMAR) after 6 months, respectively. A closure rate of 95.1 % was achieved. The morphological parameter photoreceptor IS/OS integrity was measured semiquantitatively and showed a positive correlation to BCVA.

CONCLUSION:
Transconjunctival sutureless pars plana vitrectomy and Brilliant Peel (BP)-assisted ILM peeling in patients with macular holes is a very safe procedure and leads to good functional and anatomic results. The integrity of the IS/OS segment is a good predictive parameter for BCVA improvement after macular hole surgery.

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Ooi YL, Khang TF, Naidu M, Fong KC:

THE STRUCTURAL EFFECT OF INTRAVITREAL BRILLIANT BLUE G AND INDOCYANINE GREEN IN RATS EYES.

Eye (Lond). 2013;27(3):425-31

PURPOSE:
To compare the potential retinal toxicity of two commercially Brilliant blue G dyes (Brilliant Peel and Ocublue Plus) and Indocyanine green (ICG) at usual clinical concentration.

METHODS:
Brilliant Peel 0.025% (n=9), Ocublue Plus 0.025% (n=9), and ICG 0.05% (n=9) were injected intravitreally into Sprague-Dawley rat left eyes with balanced salt solution injected in the contralateral eyes as control. Evaluation of the effect of the dyes on retinal architecture was done by histological analysis of neurosensory retinal thickness and retinal ganglion cell (RGC) counts 7 days after intravitreal injection. Paired t-test was done to detect the presence of biologically significant thinning in neurosensory retina and five retinal layers for each dye (paired t-tests). One-way ANOVA and Tukey's Honestly Significant Difference test were used to assess whether different dyes caused significant thinning in mean neurosensory retinal thickness and reduction of mean RGC density.

RESULTS:
Eyes treated with ICG had significantly thinner mean total neurosensory retinal thickness compared with the control eyes (P-value=0.01), followed by those treated with Ocublue Plus (P-value=0.03). Brilliant Peel did not cause significant thinning in any of the five retinal layers (all P-values>0.05). No significant difference in mean thinning of the total retinal thickness was detected between dyes (P-value=0.11). The mean thickness of the photoreceptor outer segment and outer plexiform layers were significantly reduced in ICG-injected eyes when compared with the control eyes (P-value=0.02). No significant difference in mean thinning between the three dyes was detected at all five retinal layers using one-way ANOVA (all P-values>0.35). RGC density was significantly reduced for ICG (P-value=0.01) but only marginally for Ocublue Plus (P-value=0.05). No significant reduction in RGC density was observed for Brilliant Peel (P-value=0.2).

CONCLUSION:
Intravitreal Brilliant Peel is safe to rats retina. The retinal thinning and reduction in RGC density induced by Ocublue Plus requires further studies to determine the safety profile of this product. Potential retinal toxicity is seen with ICG 0.05%.

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Baba T, Hagiwara A, Sato E, Arai M, Oshitari T, Yamamoto S:

COMPARISON OF VITRECTOMY WITH BRILLIANT BLUE G OR INDOCYANINE GREEN ON RETINAL MICROSTRUCTURE AND FUNCTION OF EYES WITH MACULAR HOLE.

Ophthalmology 2012;119(12):2609-15.

PURPOSE:
To evaluate the microstructure of the inner and outer retina and the visual function after macular hole (MH) surgery using brilliant blue G (BBG) or indocyanine green (ICG) to make the internal limiting membrane (ILM) more visible.

DESIGN:
Comparative, retrospective, interventional case series.

PARTICIPANTS:
Sixty-three eyes of 63 consecutive cases with MH were studied. Thirty-five eyes of 35 cases were treated with BBG between January and August 2011. Twenty-eight eyes of 28 MH cases were treated with ICG from April 2009 through April 2010.

METHODS:
Vitrectomy was performed with a 23-gauge system and 0.25 mg/ml BBG or with 0.125% ICG.

MAIN OUTCOME MEASURES:
The best-corrected visual acuity (BCVA) and the microperimetry-determined retinal sensitivity were measured at baseline and at 3 and 6 months after surgery. The length of the defect of the photoreceptor inner segment/outer segment (IS/OS) junction and external limiting membrane (ELM), the central foveal thickness (CFT), and the thickness of the ganglion cell complex (GCC) were measured in the spectral-domain optical coherence tomographic images.

RESULTS:
The average BCVA was significantly better in the BBG group than in the ICG group at 3 months (P = 0.021) and 6 months (P = 0.045) after surgery. The mean retinal sensitivity in the BBG group was improved significantly in the central 2° at 3 and 6 months (P = 0.001 and P = 0.030, respectively), but was not significantly improved in the adjacent 10°. The length of IS/OS junction defect was significantly shorter in the BBG group at 3 months (P = 0.048), but was not significantly different at 6 months (P = 0.135). The length of ELM defect and the GCC thickness were not significantly different between the 2 groups at 3 and 6 months. The CFT was significantly thinner in the ICG group than in the BBG group at 3 and 6 months (P = 0.013 and P = 0.001, respectively).

CONCLUSIONS:
The postoperative BCVA and retinal sensitivity in the central 2° were better in eyes after BBG-assisted vitrectomy. The restoration of IS/OS junction was faster in the BBG group, and the CFT was significantly thinner in eyes after ICG. Brilliant blue G may be a better agent than ICG to make the ILM more visible.

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Januschowski K, Mueller S, Spitzer MS, Schramm C, Doycheva D, Bartz-Schmidt KU, Szurman P:

EVALUATING RETINAL TOXICITY OF A NEW HEAVY INTRAOCULAR DYE, USING A MODEL OF PERFUSED AND ISOLATED RETINAL CULTURES OF BOVINE AND HUMAN ORIGIN.

Graefes Arch Clin Exp Ophthalmol 2012;250(7):1013-22.

BACKGROUND:
Dyes such as brilliant blue (BBG) are used during vitreoretinal surgery to visualize anatomical structures. By adding deuterium oxide (D2O), surgeons have tried to create a dye mixture heavier than water to facilitate staining of the inner limiting membrane (ILM) without prior fluid-air exchange. This study investigated the effect of 0.4 ml BBG (Fluoron, Ulm, Germany) mixed with 0.13 ml/ml D2O and D2O on retinal function of a pseudo in vivo model using bovine and human whole mount cultures.

METHODS:
Bovine and human retinas were superfused, and the electroretinogram (ERG) was recorded. BBG with 0.13 ml/ml D2O and D2O were applied epiretinally, different staining periods (10, 30, 60 and 120 s) were tested, and ERG recovery was monitored. 1 mM aspartate was added to the nutrient solution to examine the photoreceptor reaction.

RESULTS:
Reductions of the a- and b-wave amplitudes were found directly after exposure with BBG with 0.13 ml/ml D2O and with D2O in all test series. These effects on the electroretinogram were rapidly and completely reversible within the recovery time for all exposure times. ERG amplitudes measured after dye application at the end of the washout did not differ significantly from those recorded before staining.

CONCLUSIONS:
The clinically used mixture of BBG/D2O seems to be safe for clinical use. Staining periods of more than 120 seconds were not tested.

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Pelayes DE, Kuhn F, Folgar AM, Takahashi W, Bastien A, Vinicius PN, Zarate JO:

COMPARISON OF VITRECTOMY WITH BRILLIANT BLUE G OR INDOCYANINE GREEN ON RETINAL MICROSTRUCTURE AND FUNCTION OF EYES WITH MACULAR HOLE.

Ophthalmic Res 2012;48 Suppl 1:21-5.

BACKGROUND:
Brilliant blue G (BBG) is frequently used in chromovitrectomy to facilitate internal limiting membrane (ILM) peeling. A study was initiated to evaluate if heavy BBG is safe and effective in staining the ILM. Methods: We studied 30 eyes, 23 with idiopathic macular holes and 7 of patients with diabetic macular edema. Removal of the ILMs was assisted by heavy BBG staining. In cases with histopathological correlation the ILMs were evaluated with hematoxylin and eosin, Masson’s trichrome, periodic acid-Schiff and glial fibrillary acidic protein staining. In addition, immunohistochemistry was also performed using specific antibodies for vimentin, neuron-specific enolase, factor VIII and CD68. Using the Image-Pro Plus software of Media Cybernetics Co. we found an average thickness in ILMs. Results: Of the ILM specimens sent, 19/30 (63.33%) could not be processed properly because of the limited sample material, recognizing only fragments of dispersed fibrillar material. In macular hole ILMs we found an average thickness of 1.3 ± 0.65 µm, and in diabetic macular edema ILMs an average thickness of 6.2 ± 1.4 µm. Conclusions: In heavy BBG-assisted ILM peeling we observed no intraoperative or postoperative complications after a mean follow-up of 12 months. Heavy BBG could be an effective and safe vehicle for staining the ILM.

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Gerding H, Timmermann M, Thelen U:

INTRAVITAL STAINING OF THE INTERNAL LIMITING MEMBRANE WITH A NOVEL HEAVY SOLUTION OF BRILLIANT BLUE G.

Klin Monbl Augenheilkd 2011;228(4):298-301.

BACKGROUND:
The aim of this study was to investigate the hydrodynamic properties and clinical efficacy of a novel heavier-than-water dye (BBG-D2O) designed for staining of the internal limiting membrane (ILM) during vitreoretinal procedures, consisting of brilliant blue G (BBG, 0.25 mg/mL) with the addition of 13 % of deuterium oxide (D2O).

MATERIAL, PATIENTS AND METHODS:
The gravity-related hydrodynamic distribution of BBG-D2O was measured in 7 experiments using standard test cuvettes filled with balanced salt solution. BBG-D2O was applied in 3 patients (2 × epiretinal membrane (ERM), 1 × vitreous traction and lamellar macular hole) for the staining of the ILM.

RESULTS:
Compared to standard solutions of BBG the heavy version of the dye (BBG-D2O) presented a rapid flow towards the bottom of test cuvettes. After 15 seconds the concentration of BBG solutions in the lowest 25 % of the cuvette volumes was 4.2 ± 0.2 µg/mL (mean ± standard deviation) compared to 19.0 ± 2.6 µg/mL of BBG-D2O. Clinically BBG-D2O resulted in a strong staining effect of the ILM, comparable to conventional indocyanine green (ICG) solution and clearly more intensive than that of conventional BBG solution of the same concentration (0.25 mg/mL). The intensive staining effect of primary applied BBG-D2O before epiretinal membrane removal allowed an en bloc peeling of ILM and ERM as a one-step procedure. No sign of any adverse effects related to the use of BBG-D2O were observed.

CONCLUSIONS:
Heavy brilliant blue G (BBG-D2O) provides a significantly improved staining effect of the ILM and by this makes ILM peeling more efficient, easier, faster and less traumatic.

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Haritoglou C, Schumann RG, Kampik A, Gandorfer A:

HEAVY BRILLIANT BLUE G FOR INTERNAL LIMITING MEMBRANE STAINING.

Retina 2011;31(2):405-7.

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Höing A, Remy M, Dirisamer M, Priglinger S, Schönfeld CL, Kampik A, Haritoglou C:

AN IN-VIVO EVALUATION OF BRILLIANT BLUE G IN MACULAR SURGERY.

Klin Monbl Augenheilkd 2011;228(8):724-8.

POBJECTIVE:
The aim of this study was to evaluate the functional outcome of Brilliant Blue G (BBG) and the staining properties in macular surgery.

METHODS:
BBG was applied during vitrectomy for macular holes (n = 21) or epiretinal membranes (n = 18) in a prospective, non-comparative consecutive series of patients (Brilliant Peel®; Fluoron® GmbH, Neu-Ulm, Germany). Before and after surgery all patients underwent a complete clinical examination including measurement of best corrected visual acuity and intraocular pressure, perimetry, fundus photography and optical coherence tomography.

RESULTS:
Vitrectomy was performed in combination with a cataract operation in 14 patients. All macular holes were closed successfully. Visual acuity was in average 0.16 preoperatively in macular hole cases and increased up to 0.4 after 6 months. Visual acuity of patients with epiretinal membranes changed on average from 0.3 to 0.45 after 6 months. The retina thickness in patients with epiretinal membranes was initially 402.6 µm according to the OCT and 304.7 µm after 6 months postoperatively. No toxic effects attributable to the dye were noted during patient follow-up, especially all perimetry tests were normal.

CONCLUSIONS:
Brilliant blue provides a sufficient and selective staining of the ILM. No retinal toxicity or adverse effects related to the dye were observed in this study. The long-term safety of this dye will have to be evaluated in larger patient series and a longer follow-up.

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Wirbelauer C, Häberle H, Pham DT:

CLINICAL EXPERIENCE WITH BRILLIANT BLUE G STAINING OF THE RETINAL SURFACE.

Klin Monbl Augenheilkd 2011;228(1):62-5.

BACKGROUND:
Staining of the retinal surface has improved the intraoperative removal of semitransparent membranes during macular surgery. The purpose of this study was to evaluate the clinical experiences with brilliant blue G (BBG) staining of the retinal surface.

METHODS:
BBG (Brilliant peel, Fluoron) was applied during vitrectomy and macular surgery in 43 patients. In 47 % there was a macular hole (MH), whereas 53 % had epiretinal membranes (ERM). Intraoperatively BBG was applied on the retinal surface under infusion or air conditions for 30 - 60 s. In MH the internal limiting membrane (ILM) and in ERM the membrane was removed. Postoperatively all patients were examined on average after 9 weeks.

RESULTS:
Although intraoperative BBG staining was less intensive compared to ICG staining, the staining was sufficient to safely remove the semitransparent membranes in all cases. In all patients with MH hole closure was achieved, and in 96 % with ERM the metamorphopsiae decreased. The mean decimal visual acuity increased from 0.25 ± 0.13 to 0.37 ± 0.20 and improved in 63 % of the patients. Clinically, there were no toxic side-effects from BBG staining.

CONCLUSIONS:
BBG allowed a complete and selective staining of the retinal surface. Thus, ILM and ERM could be removed safely during macular surgery. No clinical retinal toxicity was observed.

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Vioron

Keratoplastik

Melles GRJ, San Ong T, Ververs B, van der Wees J (2006):

DESCEMET MEMBRANE ENDOTHELIAL KERATOPLASTY (DMEK).

Cornea 25, 987-990

PURPOSE:
To describe Descemet membrane endothelial keratoplasty (DMEK) with organ cultured Descemet membrane (DM) in a human cadaver eye model and a patient with Fuchs endothelial dystrophy.

METHODS:
In 10 human cadaver eyes and 1 patient eye, a 3.5-mm clear corneal tunnel incision was made. The anterior chamber was filled with air, and the DM was stripped off from the posterior stroma. From organ-cultured donor corneo-scleral rims, 9.0-mm-diameter "DM rolls" were harvested. Each donor DM roll was inserted into a recipient anterior chamber, positioned onto the posterior stroma, and kept in position by completely filling the anterior chamber with air for 30 minutes.

RESULTS:
In all recipient eyes, the donor DM maintained its position after a 30-minute air-fill of the anterior chamber followed by an air-liquid exchange. In the patient's eye, 1 week after transplantation, best-corrected visual acuity was 1.0 (20/20) with the patient's preoperative refraction, and the endothelial cell density averaged 2350 cells/mm.

CONCLUSION:
DMEK may provide quick visual rehabilitation in the treatment of corneal endothelial disorders by transplantation of an organ-cultured DM transplanted through a clear corneal tunnel incision. DMEK may be a highly accessible procedure to corneal surgeons, because donor DM sheets can be prepared from preserved corneo-scleral rims.

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Ham L, Dapena I, van Luijk C, van der Wees J, Melles GRJ (2009):

DESCEMET MEMBRANE ENDOTHELIAL KERATOPLASTY (DMEK) FOR FUCHS ENDOTHELIAL DYSTROPHY: REVIEW OF THE FIRST 50 CONSECUTIVE CASES.

Eye 23, 1990-1998

PURPOSE:
To evaluate the clinical outcome and complications of Descemet membrane endothelial keratoplasty (DMEK), using Descemet-stripping endothelial keratoplasty (DSEK) as a back-up procedure, in the management of Fuchs endothelial dystrophy.

DESIGN:
Non-randomised prospective clinical study.

METHODS:
The first fifty consecutive eyes that underwent DMEK, that is, transplantation of an isolated donor Descemet membrane carrying its endothelium, for Fuchs endothelial dystrophy were evaluated. In all eyes, the best-corrected visual acuity (BCVA) as well as the endothelial cell density (ECD) was measured before and at 6 months after surgery, as clinical outcome parameters.

RESULTS:
Ten patients required a secondary DSEK for failed DMEK. In the remaining 40 DMEK eyes, 95% had a BCVA of > or = 20/40 (> or = 0.5) and 75% > or = 20/25 (> or = 0.8) at 6 months after surgery. ECD averaged 2618 (+ or - 201) cells/mm(2) before, and 1876 (+ or - 522) cells/mm(2) at 6 months after surgery (n = 35). When the outcomes of DMEK and secondary DSEK procedures were combined, 94% reached a BCVA of > or = 20/40 (> or = 0.5) and 66% > or = 20/25 (> or = 0.8) (n = 47), and ECD averaged 2623 (+ or - 193) cells/mm(2) before, and 1815 (+ or - 578) cells/mm(2) at 6 months after surgery (n = 43).

CONCLUSION:
With DSEK as a back-up procedure, DMEK may provide relatively quick and complete visual rehabilitation in a majority of patients operated on for Fuchs endothelial dystrophy. Endothelial cell survival may be similar to earlier types of (lamellar) keratoplasty. Early graft detachment was the main complication in this first series of DMEK surgeries for Fuchs endothelial dystrophy.

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Cursiefen C, Kruse FE (2010):

DMEK: POSTERIORE LAMELLÄRE KERATOPLASTIKTECHNIK.

Ophthalmologe 107, 370-376

BACKGROUND:
Penetrating keratoplasty is at present the gold standard for surgical treatment of corneal endothelial pathologies but tremendous progress has been made in recent years in improving the technology of (posterior) lamellar keratoplasty techniques, such as Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK).

METHODS:
A review of the literature was carried out using PUBMED and own clinical and experimental data.

RESULTS:
Isolated transplantation of Descemet's membrane with endothelial cells after stripping the host Descemet's membrane is a new surgical technique for Fuchs endothelial dystrophy and pseudophakic bullous keratopathy. Visual rehabilitation seems to be faster and better with DMEK compared to penetrating keratoplasty.

CONCLUSION:
Posterior lamellar keratoplasty techniques such as DMEK will replace penetrating keratoplasty as the gold standard for treatment of a large segment of corneal endothelial pathologies.

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Droutsas K, Ham L, Dapena I, Geerling G, Oellerich S, Melles G (2010):

VISUS NACH DESCEMET-MEMBRAN ENDOTHELKERATOPLASTIK (DMEK): ERGEBNISSE DER ERSTEN 100 EINGRIFFE BEI FUCHS’SCHER ENDOTHELDYSTROPHIE.

Klin Monatsbl Augenheilkd 227, 467-477

Purpose:
The aim of this study was to evaluate the visual outcome and endothelial cell density in the first series of 100 eyes after Descemet membrane endothelial keratoplasty (DMEK) for the treatment of Fuchs endothelial dystrophy. Design: This was a non-randomised prospective clinical trial.

Methods:
The first 100 consecutive eyes (87 patients) that underwent DMEK (i. e., transplantation of an isolated donor Descemet membrane carrying its endothelium) for Fuchs endothelial dystrophy were evaluated. In all eyes, the best corrected visual acuity (BCVA) as well as the endothelial cell density (ECD) were measured before and at one, three and six months after surgery.

Results:
In eyes with a functional DMEK graft and good visual potential (n = 78), the BCVA was ≥ 20 / 40 (≥ 0.5) in 79 % after 1 month, 94 % after 3 months, and 96 % after six months; ≥ 20 / 25 (≥ 0.8) in respectively 54 %, 64 %, and 74 %, and ≥ 20 / 20 (≥ 1.0) in respectively 26 %, 36 %, and 45 %. In this group, ECD averaged 2630 (± 190) cells/mm2 before, and 1800 (± 540) cells/mm2 at six months after surgery (n = 76). In 15 eyes, a secondary ”Descemet stripping endothelial keratoplasty” (DSEK) was performed. When the outcomes of DMEK and secondary DSEK procedures were combined, 91 % reached a BCVA of ≥ 20 / 40 (≥ 0.5), 65 % ≥ 20 / 25 (≥ 0.8) and 38 % ≥ 20 / 25 (≥ 1.0) at six months after surgery (n = 93). For the whole group, ECD averaged 2620 (± 190) cells/mm2 before, and 1730 (± 590) cells/mm2 at six months after surgery (n = 89).

Conclusion:
DMEK may provide relatively quick and nearly complete visual rehabilitation in a majority of patients operated on for Fuchs endothelial dystrophy. Endothelial cell survival may be similar to earlier types of endothelial keratoplasty. Early graft detachment (19 cases) was the main complication in this first series of DMEK surgeries.

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Dapena I, Moutsouris K, Droutsas K, Ham L, van Dijk K, Melles GRJ (2011):

STANDARDIZED “NO-TOUCH” TECHNIQUE FOR DESCEMET MEMBRANE ENDOTHELIAL KERATOPLASTY.

Arch Ophthalmol 129, 88-94

Abstract:
We describe a standardized technique for "no-touch" isolated Descemet membrane transplant, ie, Descemet membrane endothelial keratoplasty (DMEK). All essential steps, including patient preparation and descemetorhexis as well as DMEK graft implantation, orientation, unrolling, centering, appositioning, and fixation, are described in detail. In the management of Fuchs endothelial dystrophy, the technique may provide a best-corrected visual acuity of 20/25 or better (≥ 0.8) in three-quarters of cases and an endothelial cell density of about 1800 to 2000 cells/mm(2) at 6 months after surgery. No-touch DMEK may therefore be a safe and effective procedure for the treatment of corneal endothelial disorders, making endothelial keratoplasty accessible to most corneal surgeons without requiring major investments while providing an unprecedented visual rehabilitation rate and outcome.

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Dirisamer M, Ham L, Dapena I, Moutsouris K, Droutsas K, van Dijk K, Frank LE, Oellerich S, Melles GR (2011):

EFFICACY OF DESCEMET MEMBRANE ENDOTHELIAL KERATOPLASTY: CLINICAL OUTCOME OF 200 CONSECUTIVE CASES AFTER A LEARNING CURVE OF 25 CASES.

Arch Ophthalmol 129, 1435-1443

OBJECTIVE:
To evaluate Descemet membrane endothelial keratoplasty for management of corneal endothelial disorders.

METHODS:
Descemet membrane endothelial keratoplasty was performed in 200 patients with Fuchs endothelial dystrophy or bullous keratopathy. Best-corrected visual acuity, subjective and objective refractive outcome and stability, and endothelial cell density were evaluated at 1, 3, and 6 months postoperatively, and intraoperative and postoperative complications were documented.

RESULTS:
At 6 months, 94% reached a best-corrected visual acuity of 20/40 or better (≥0.5); 77%, 20/25 or better (≥0.8); 47%, 20/20 or better (≥1.0), and 16%, 20/17 or better (≥1.2) (n = 159). The preoperative to 6 months' postoperative spherical equivalent showed a mean (SD) +0.38 (1.2) diopter hyperopic shift (P = .001) that correlated with a decrease in central corneal thickness (n = 143) (P = .047). Two-thirds of eyes showed refractive stability at 3 months. Donor endothelial cell density showed a decrease from mean (SD) 2560 (186) cells/mm(2) preoperatively to 1690 (520) cells/mm(2) at 6 months after surgery (n = 173). Graft detachment was the main complication and occurred in 18 eyes (9%). Recipient Descemet membrane remnants were present in 12 eyes (6%). Secondary glaucoma was seen in 8 eyes (4%), of which 4 showed air-bubble dislocation behind the iris. In 2 of 33 phakic eyes (6%), a secondary cataract developed requiring phacoemulsification.

CONCLUSIONS:
Descemet membrane endothelial keratoplasty may offer complete visual rehabilitation within 1 to 6 months after surgery in a majority of eyes. Similar to earlier keratoplasty techniques, Descemet membrane endothelial keratoplasty may be associated with a one-third decrease in donor endothelial cell density in the early postoperative phase. Incidence of (partial) graft detachment stabilized at about 5% but could be further reduced by patient selection and/or technique modification.

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Heindl LM, Riss S, Bachmann BO, Laaser K, Kruse FE, Cursiefen C (2011):

SPLIT CORNEA TRANSPLANTATION FOR 2 RECIPIENTS. A NEW STRATEGY TO REDUCE CORNEAL TISSUE COST AND SHORTAGE.

Ophthalmology 118, 294-301

PURPOSE:
To evaluate the feasibility of using a single donor cornea for 2 recipients by combining deep anterior lamellar keratoplasty (DALK) and Descemet's membrane endothelial keratoplasty (DMEK) surgeries on the same day.

DESIGN:
Single-center, nonrandomized, prospective, interventional case series.

PARTICIPANTS:
Twelve consecutive donor corneas were scheduled for split cornea transplantation combining DALK for a keratoconus patient and DMEK for a Fuchs' endothelial dystrophy patient on the same surgery day.

METHODS:
First, a big-bubble DALK procedure was performed for the keratoconus eye. When bare Descemet's membrane was prepared successfully requiring no conversion to penetrating keratoplasty (PK), then during surgery the donor, endothelium-Descemet's membrane layer was removed and stored for subsequent DMEK in a second patient, and the remaining anterior lamella of the donor cornea was used to complete the DALK surgery. Afterward, a DMEK procedure was performed on the second patient with Fuchs' endothelial dystrophy, grafting the stored endothelium-Descemet's membrane layer of the original donor button.

MAIN OUTCOME MEASURES:
Success of using a single donor cornea for 2 recipient eyes, best spectacle-corrected visual acuity (BSCVA), and complication rates within 6 months follow-up.

RESULTS:
A single donor cornea could be used for 2 recipients in 10 of 12 donor buttons (83%). In 2 cases (17%), the DALK procedure had to be converted to PK requiring a full-thickness corneal graft. Therefore, 10 donor corneas (45%) could be saved. Six months after surgery, mean BSCVA was 20/35 (range, 20/50-20/25) in 10 eyes that underwent successful DALK, 20/50 (range, 20/63-20/40) in 2 eyes that underwent conversion from DALK to PK, and 20/31 (range, 20/50-20/16) in 10 eyes that underwent DMEK. Postoperative complications after DALK included Descemet's folds in 3 eyes (30%) and epitheliopathy in 2 eyes (20%). After DMEK, partial graft detachment occurred in 5 eyes (50%) and was managed successfully with intracameral air reinjection. All corneas remained clear up to 6 months after surgery.

CONCLUSIONS:
Split use of donor corneal tissue for combined DALK and DMEK procedures in 2 recipients on the same surgery day is a promising strategy to reduce donor shortage and cost in corneal transplantation surgery in the future.

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Güell JL, Morral M, Gris O, Elies D, Manero F (2013):

BIMANUAL TECHNIQUE FOR INSERTION AND POSITIONING OF ENDOTHELIAL-DESCEMET MEMBRANE GRAFT IN DESCEMET MEMBRANE ENDOTHELIAL KERATOPLASTY.

Cornea 32, 1522-1526

PURPOSE:
To describe a new bimanual technique for insertion and positioning of endothelium-Descemet membrane (EDM) grafts in Descemet membrane endothelial keratoplasty (DMEK).

METHODS:
Prospective, noncomparative, consecutive interventional case series, including 15 pseudophakic eyes of 15 patients treated with DMEK at the Instituto de Microcirugia Ocular, Barcelona, Spain. A bimanual infusion technique was used to introduce and position donor's EDM. Partial tamponade was achieved with 20% sulfur hexafluoride (SF6). Intraocular manipulation time of EDM grafts, rebubbling rate, and endothelial cell density were evaluated.

RESULTS:
Six months postoperatively, mean uncorrected visual acuity and best spectacle-corrected visual acuity (BSCVA) improved from 20/100 to 20/50 and from 20/80 to 20/25, respectively. Six eyes (40%) had ≥ 20/20 BSCVA, and 13 (86%) eyes had ≥ 20/30 BSCVA. Mean donor cell density decreased from 2690 ± 302 to 1998 ± 621 cells per square millimeter, representing a mean cell loss of 26% ± 20%. EDM was stripped successfully in all cases. Mean intraocular manipulation time of donor's EDM (interval between main incision closure and final EDM positioning) was 4.10 ± 0.5 minutes. Intracameral air reinjection was needed in 1 case (6.6%) with a partial peripheral graft detachment. No episodes of immunologic graft rejection were documented.

CONCLUSIONS:
Insertion and positioning of EDM grafts in DMEK was successfully achieved using this bimanual infusion technique and 20% SF6 partial tamponade, with a low intraocular manipulation time and very low postoperative rebubbling rates, regardless of the preservation method and the donor's age. However, prospective comparative studies are required to demonstrate the long-term safety compared with other approaches.

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Ciechanowski PP, Droutsas K, Baydoun L, Dirisamer M, Oellerich S, Melles GR (2014):

STANDARDISIERTE DESCEMET-MEMBRAN-ENDOTHELKERATOPLASTIK (DMEK). TECHNIK UND AKTUELLE ERGEBNISSE.

Ophthalmologe 111, 1041-1049

Background
The procedure of posterior lamellar keratoplasty has now become established as first choice therapy for the treatment of corneal endothelial diseases, with Descemet membrane endothelial keratoplasty (DMEK) as the most recent refinement of endothelial keratoplasty techniques. In this study the outcome of 400 consecutive cases after standardized no-touch DMEK was evaluated.

Methods
This was a non-randomized retrospective clinical study of 400 consecutive eyes in 321 patients who underwent standard DMEK. Outcome measures included best corrected visual acuity (BCVA) preoperatively and postoperatively at 1, 3 and 6 months, endothelial cell density (ECD), pachymetry and complications within the first 6 months. In addition two subgroups were analyzed (subgroup I cases 1–200 and subgroup II cases 201–400).

Results
At 6 months postoperatively 80 % of all eyes had a BCVA of ≥ 20/25 (≥ 0.8), 44 % of ≥ 20/20 (≥ 1.0) and 14 % of ≥ 20/18 (≥ 1.2). There were no significant differences between the two subgroups. The mean ECD preoperatively was 2,542 (± 217) cells/mm2 and 6 months postoperatively 1,622 (± 500) cells/mm2. The mean ECD decrease was 36 % 6 months after DMEK. No difference between the subgroups was noted. In 5 % a re-operation was needed of which 75 % were performed in subgroup I.

Conclusion
With the standardized no-touch DMEK technique a rapid and nearly complete visual rehabilitation as well as ECD values similar to earlier endothelial keratoplasty techniques can be achieved. Therefore DMEK may become the preferred treatment for corneal endothelial disorders.


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Baydoun L, van Dijk K, Dapena I, Musa FU, Liarakos V, Ham L, Melles GRJ (2015):

REPEAT DESCEMET MEMBRANE ENDOTHELIAL KERATOPLASTY AFTER COMPLICATED PRIMARY DESCEMET MEMBRANE ENDOTHELIAL KERATOPLASTY.

Ophthalmology 122, 8-16

PURPOSE:
To describe the clinical outcome and complications of repeat Descemet membrane endothelial keratoplasty (re-DMEK).

DESIGN:
Retrospective case series study at a tertiary referral center.

PARTICIPANTS:
From a series of 550 consecutive DMEK surgeries with ≥ 6 months follow-up, 17 eyes underwent re-DMEK for graft detachment after initial DMEK (n = 14) and/or endothelial graft failure (n = 3). The outcomes were compared with an age-matched control group of uncomplicated primary DMEK surgeries.

METHODS:
The re-DMEK eyes were evaluated for best-corrected visual acuity (BCVA), densitometry, endothelial cell density (ECD), pachymetry, and intraoperative and postoperative complications.

MAIN OUTCOME MEASURES:
Feasibility and clinical outcome of re-DMEK.

RESULTS:
In all eyes, re-DMEK was uneventful. At 12 months, 12 of 14 eyes (86%) achieved a BCVA of ≥ 20/40 (≥ 0.5); 8 of 14 eyes (57%) achieved ≥ 20/25 (≥ 0.8), 3 of 14 eyes (21%) achieved ≥ 20/20 (≥ 1.0), and 1 eye (7%) achieved 20/17 (1.2); 5 eyes were fitted with a contact lens. Average donor ECD decreased from 2580 ± 173 cells/mm(2) before to 1390 ± 466 cells/mm(2) at 6 months after surgery, and pachymetry from 703 ± 126 μm to 515 ± 39 μm, respectively. No difference in densitometry could be detected between re-DMEK and control eyes (P = 0.99). Complications after re-DMEK included primary graft failure (n = 1), secondary graft failure (n = 2), graft detachment requiring rebubbling (n = 1), secondary glaucoma (n = 2), cataract (n = 1), and corneal ulcer (n = 1). One eye received tertiary DMEK.

CONCLUSIONS:
In the management of persistent graft detachment and graft failure after primary DMEK, re-DMEK proved a feasible procedure. Acceptable BCVA may be achieved, albeit lower than after DMEK in virgin eyes, and some cases may benefit from contact lens fitting. Complications after re-DMEK may be better anticipated than after primary DMEK because graft detachment and graft failure tended to recur, suggesting that intrinsic properties of the host eye play a role in graft adherence and graft failure.

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Vioron

Kapsulorhexis

Melles GRJ, de Waard PWT, Pameyer JH, Beekhuis WH (1999):

TRYPAN BLUE CAPSULE STAINING TO VISUALIZE THE CAPSULORHEXIS IN CATARACT SURGERY.

J Cataract Refract Surg 25, 7-9

Abstract
A capsulorhexis may be difficult to perform in the absence of a red fundus reflex. Using 0.1 mL of trypan blue 0.1% to stain the anterior capsule in 30 patients with a mature cataract enabled us to visualize the capsulorhexis during phacoemulsification. No adverse reactions were observed up to 12 months after surgery. Trypan blue staining of the anterior capsule appears to be a safe technique to facilitate the performance of a capsulorhexis in the absence of a red fundus reflex.

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Melles GRJ, de Waard PWT, Pameijer JH, Beekhuis WH (1999):

FÄRBUNG DER LINSENKAPSEL MIT TRYPANBLAU ZUR VISUALISIERUNG DER KAPSULORHEXIS BEI MATURKATARAKTCHIRURGIE.

Klin Monatsbl Augenheilkd 215, 342-344

Background:
A capsulorhexis may be difficult to perform in the absence of a red fundus reflex.

Patients and Methods:
After application of 0.3 mL trypan blue 0.1%, a quick and homogeneous staining of the anterior lens capsule was obtained in 100 patients with a mature cataract, to visualize the capsulorhexis during a phacoemulsification procedure.

Results:
No adverse reactions related to the dye were observed up to 18 months after surgery.

Conclusion:
Trypan blue staining of the anterior lens capsule may therefore be a safe technique to facilitate the performance of a capsulorhexis in the absence of a red fundus reflex.

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Werner L, Pandey SK, Escobar-Gomez M, Hoddinott DS, Apple DJ (2000):

DYE-ENHANCED CATARACT SURGERY. PART 2: LEARNING CRITICAL STEPS OF PHACOEMULSIFICATION.

J Cataract Refract Surg 26, 1060-1065

PURPOSE:
To use capsule dyes to enhance visualization to learn and perform various critical steps of the phacoemulsification procedure in a laboratory setting using postmortem human eyes.

SETTING:
Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA.

METHODS:
Indocyanine green 0.5% (ICG) and trypan blue 0.1% were used to enhance visualization for performing critical steps of phacoemulsification in 8 human eyes obtained postmortem. All eyes were prepared according to the Miyake-Apple posterior video technique. After a continuous curvilinear capsulorhexis (CCC) was made, the dyes were used to enhance visualization for hydrodissection, hydrodelineation, and various maneuvers for nuclear emulsification and cortical cleanup. In 8 eyes, all the aforementioned steps were performed without using dye (control group).

RESULTS:
Both dyes helped enhance visualization during the critical steps of phacoemulsification. The use of a dye solution instead of balanced salt solution (BSS) for hydrodissection/delineation helped localize the complete plane of cleavage between the capsule and cortex and the nucleus-epinucleus complex. During various nuclear sculpting maneuvers, the use of dye helped visualization of the position of the phaco tip and its relation to the posterior capsule. It also helped localize remaining cortical fibers, facilitating complete cleaning of the capsular bag.

CONCLUSIONS:
Dye-enhanced cataract surgery was useful in learning various critical steps of phacoemulsification in a wet laboratory setting.

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De Waard PWT, Budo CJ, Melles GRJ (2002):

TRYPAN BLUE CAPSULAR STAINING TO “FIND” THE LEADING EDGE OF A “LOST” CAPSULORHEXIS.

Am J Ophthalmology 134, 271-272

PURPOSE:
To describe an effective surgical technique to visualize an obscured leading edge of a capsulorhexis.

DESIGN:
Prospective, interventional case series.

METHODS:
In six eyes of six patients in which the capsulorhexis was started but could no longer be seen during surgery, the anterior chamber was irrigated to remove all viscoelastic, and 0.3-ml trypan blue 0.06% was applied onto the anterior lens capsule to stain and visualize the leading edge of the capsulorhexis.

RESULTS:
In all patients, the leading edge of the capsulorhexis was quickly visualized by using the dye. No adverse reactions were observed up to 1 year after surgery.

CONCLUSION:
Trypan blue staining of the anterior lens capsule is an effective and apparently safe technique to "find" a "lost" capsulorhexis during surgery.

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Jacob S, Agarwal A, Agarwal A, Agarwal S, Chowdhary S, Chowdhary R, Bagmar AA (2002):

TRYPAN BLUE AS AN ADJUNCT FOR SAFE PHACOEMULSIFICATION IN EYES WITH WHITE CATARACT.

J Cataract Refract Surg 28, 1819-1825

PURPOSE:
To assess the feasibility, risks, and postoperative outcomes of phacoemulsification with posterior chamber intraocular lens (PC IOL) implantation in cases of white cataract with the use of trypan blue as an adjunct for performing continuous curvilinear capsulorhexis (CCC) in the absence of a red reflex.

SETTING:
Dr. Agarwal's Eye Hospital, Chennai, India.

METHODS:
This prospective study comprised 52 eyes of 52 patients with white cataract that had phacoemulsification through a clear corneal temporal incision with PC IOL implantation. In all the cases, trypan blue was used under air to stain the anterior lens capsule and the karate-chop technique was used to emulsify the nucleus. The mean follow-up was 192.2 days.

RESULTS:
Trypan blue adequately stained the anterior lens capsule in all cases. The CCC was completed uneventfully in 96.15% eyes; 3.85% of cases had to be converted to a conventional extraction technique because of the loss of the CCC. The mean phacoemulsification time was 2.2 minutes. Intraocular complications included incomplete capsulorhexis (3.85%) and pupillary miosis (3.80%). Postoperatively, 3 eyes (5.77%) had corneal edema (striate keratopathy) and 1 eye (1.9%) had fibrin in the anterior chamber. Five eyes (9.61%) had more than 2+ cells and flare at 2 weeks. All responded well to intensive topical and subconjunctival steroids. There were no cases of endophthalmitis. The mean central endothelial cell loss, measured in 37 eyes, was 8.5%. Of the 4 eyes (7.69%) that had increased intraocular pressure (IOP) postoperatively, all responded well to medications and the IOP was normal by the second postoperative week. Fifty eyes (96.16%) had a final best corrected visual acuity of 20/30 or better. In 2 cases, the final visual acuity was worse than 20/200 because of preexisting posterior segment pathology.

CONCLUSION:
Phacoemulsification using trypan blue was safe and effective in managing white cataract and had a high success rate.

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Ozkiris A, Arslan O, Cicik E, Kyloglu N, Evereklioglu C, Nardi M, Benelli U, Bartolomet MP (2003):

OPEN-SKY CAPSULORHEXIS IN TRIPLE PROCEDURE: WITH OR WITHOUT TRYPAN BLUE?

Eur J Ophthalmol 13, 764-769

PURPOSE:
To establish the beneficial effects of trypan blue 0.1% capsule staining in open-sky capsulorrhexis during triple procedure.

METHODS:
Patients who underwent penetrating keratoplasty (PK) with phacoemulsification and intraocular lens (IOL) implantation were divided into two groups. Group 1 consisted of 31 eyes of 26 patients with a mean age 64.4 +/- 6.9 years and anterior lens capsule was stained with trypan blue 0.1% to perform open-sky capsulorrhexis. In Group 2, capsulorhexis was performed without staining of the anterior capsule in 19 eyes of 17 patients with a mean age 60.6 +/- 5.3 years. The rates of complete capsulorrhexis and intra- and postoperative capsule-related complications were compared between the groups.

RESULTS:
The most common diagnosis before PK was corneal opacification in both groups. Open-sky capsulorrhexis was not completed in 3 eyes (9.6%) in Group 1 and in 9 eyes (47.3%) in Group 2. The rates of incomplete capsulorrhexis, posterior capsule tear, and transscleral fixation IOL implantation were higher in Group 2. The diameters of capsulorrhexis were smaller than 4.5 mm in one eye in Group 1 and in two eyes in Group 2, and larger than 6.5 mm in two eyes in Group 1 and in three eyes in Group 2. Malposition of IOL, zonular dialysis, retinal detachment, and pupil capture were only observed in eyes in Group 2. In the follow-up period, there were no adverse reactions due to application of trypan blue in Group 1.

CONCLUSIONS:
Trypan blue staining of the anterior capsule during triple procedure helps the surgeon perform open-sky capsulorrhexis more easily and safely and in proper dimensions, provides positive effects on the other steps of the surgery, and decreases the rate of posterior capsule tear formation.

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Singh AJ, Sarodia UA, Brown L, Jagjivan R, Sampath R (2003):

A HISTOLOGICAL ANALYSIS OF LENS CAPSULES STAINED WITH TRYPAN BLUE FOR CAPSULORHEXIS IN PHACOEMULSIFICATION CATARACT SURGERY.

Eye 17, 567-570

BPURPOSE:
Staining of anterior lens capsules with dye to facilitate completion of continuous curvilinear capsulorrhexis is now being used more frequently in phacoemulsification of white and mature cataracts with poor red reflexes. This study examined the histological characteristics of anterior lens capsules stained with trypan blue. The layer(s) of the lens capsule that stained with dye and the extent of accumulation of dye in these layers of the lens capsule were determined. To the best of our knowledge this has not been described before.

METHODS:
A series of 10 stained lens capsules were analysed histologically. The dye used in this study consisted of a standard sterile, noninflammatory, nonpyrogenic, 2 ml solution containing 0.6 mg/ml of trypan blue. Following capsulorrhexis, samples were sent to the laboratory for histological analysis. Frozen sections (8 microm) were prepared and examined with the light microscope. All 10 capsules were cut by frozen section to preserve trypan blue staining (which would be leached by processing) and then subjected to immunohistochemistry for collagen IV. Immunohistochemical analysis using markers for type IV collagen were done on formalin-fixed specimens for morphological comparison with the frozen sections. A counterstain highlighted the epithelium.

RESULTS:
Continuous curvilinear capsulorrhexis was successfully and easily completed in all cases without any complications. Frozen section analysis using light microscopy demonstrated accumulation of trypan blue dye in the basement membrane of the lens capsule. Staining was concentrated in the portion of the membrane adjacent to the lens epithelium. The lens epithelium could not be clearly identified on the frozen sections. Consequently, immunohistochemical analysis with markers for type IV collagen was performed. A counterstain highlighted the epithelium. This confirmed that the layer staining with trypan blue was the basement membrane, a consistent feature on all the specimens.

CONCLUSION:
Trypan blue selectively stains the basement membrane of the anterior lens capsule. There is a concentration of dye in the basement membrane adjacent to the lens epithelial cell layer. The lens cortex does not appear clinically to stain with trypan blue. This enables surgeons to distinguish the lens capsule from the cortex and provides sufficient contrast for successful completion of continuous curvilinear capsulorrhexis during cataract surgery.

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Xiao Y, Wang Y, Fu Z, Hong H (2004):

STAINING THE ANTERIOR CAPSULE WITH INDOCYANINE GREEN OR TRYPAN BLUE FOR CAPSULORHEXIS IN EYES WITH WHITE CATARACT.

Int Ophthalmol 25, 273-276

AIM:
To assess the efficacy and safety of indocyanine green (ICG) 0.5% and trypan blue 0.1% for anterior capsule staining in cases of white cataract.

METHODS:
This prospective study comprised 55 eyes of 55 patients with white cataract that had phacoemulsification with foldable intraocular lens implantation. ICG in 30 eyes and trypan blue in 25 eyes were used under air to stain the anterior lens capsule. The staining patterns and the ease of creating a continuous curvilinear capsulorhexis (CCC) were assessed; the intraoperative and postoperative complications were noted. The mean follow-up was 17.68+/-1.65 months.

RESULT:
Either ICG or trypan blue stained the anterior capsule uniformly. However, the staining provided by trypan blue was slightly superior. A CCC was successfully achieved in 25 eyes (100%) with trypan blue, and 29 eyes (96.7%) with ICG, respectively. There was no significant postoperative reaction in any eye.

CONCLUSION:
The use of vital dyes such as ICG and trypan blue guarantees a complete CCC and makes it possible to deliver the benefits of phacoemulsification in the patients with white cataract.

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Chung CF, Liang CC, Lai JS, Lo ES, Lam DS (2005):

SAFETY OF TRYPAN BLUE 1% AND INDOCYANINE GREEN 0.5% IN ASSISTING VISUALIZATION OF ANTERIOR CAPSULE DURING PHACOEMULSIFICATION IN MATURE CATARACT.

J Cataract Refract Surg 31, 938-942

PPURPOSE:
To evaluate the safety of trypan blue 1% and indocyanine green (ICG) 0.5% in assisting visualization of anterior capsule during phacoemulsification in mature cataract.

SETTING:
Department of Ophthalmology, United Christian Hospital, Hong Kong, China.

METHODS:
This prospective randomized clinical trial comprised 46 eyes with mature cataract receiving phacoemulsification and posterior chamber intraocular lens implantation. They were randomized into 3 groups (trypan blue, ICG, and control without stain). Visual acuity, endothelial cell count, corneal clarity, anterior chamber reaction, and intraocular pressure (IOP) were documented before surgery and 1 week, 1 month, and 3 months postoperatively. The absolute phaco time was also recorded.

RESULTS:
There was no significant difference in absolute phaco time (P=.17), mean endothelial cell loss (P=.72 at 1 week, P=.43 at 1 month, and P=.60 at 3 months) and no significant correlation between the absolute phaco time and the change in endothelial cell count (P=.50 at 1 week, P=.10 at 1 month, and P=.60 at 3 months) in the 3 groups. None of the patients had postoperative IOP greater than 21 mm Hg. All eyes had clear corneas and a quiet anterior chamber 3 months after surgery.

CONCLUSION:
Both trypan blue 1% and ICG 0.5% are safe for assisting visualization of the anterior capsule during phacoemulsification of mature cataract.

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Wong VW, Lai TY, Lee GK, Lam PT, Lam DS (2006):

A PROSPECTIVE STUDY ON TRYPAN BLUE CAPSULE STAINING UNDER AIR VS UNDER VISCOELASTIC.

Eye 20, 820-825

AIM:
To compare the safety and effectiveness of trypan blue capsule staining under air vs under viscoelastic.

METHODS:
A total of 52 consecutive patients planned for phacoemulsification of white mature cataract were randomly assigned to trypan blue staining under air or under viscoelastic. Perioperative changes in best-corrected visual acuity (BCVA), central corneal thickness (CCT), and endothelial cell density (ECD) were compared between the two groups. The differences in operating and phacoemulsification times, staining pattern, and complications between the two groups were also recorded.

RESULTS:
Phacoemulsification of white mature cataract was performed in 50 (96%) eyes. The median preoperative BCVA was hand movement. No significant differences in the baseline characteristics were found between the two groups. At 3 months after phacoemulsification, the median BCVA improved to 0.8. The mean CCT returned to preoperative level by 1 month postoperatively and the mean ECD loss was 11.9% 3 months postoperatively. No significant differences in median BCVA, mean phacoemulsification and operation times, mean CCT, and mean ECD were found between the two groups.

CONCLUSIONS:
Trypan blue staining of the anterior lens capsule under air or under viscoelastic were similarly effective and safe methods for the phacoemulsification of white mature cataract.

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Chéour M, Ben Brahim F, Zarrad A, Khémiri N, Mghaieth K, Kraiem A (2007):

PHACOÉMULSIFICATION DES CATARACTES BLANCHES EN UTILISANT LE BLEU TRYPAN

J Fr Ophtalmol 30, 914-917

Objective
To study the results of phacoemulsification in eyes with white cataract using trypan blue for capsule staining.

Patients and methods
Thirty patients who had white cataract were included in this prospective study. They had phacoemulsification and continuous curvilinear capsulorhexis using trypan blue. Intraoperative problems related to capsulorhexis and phacoemulsification as well as postoperative outcomes where analyzed. Postoperative examinations were done at 1 day, 1 week, and 1, 3, 6, and 12 months. The mean follow-up was 10 months.

Results
Complet capsulorhexis was achieved in 26 cases. Intraoperative complications included incomplet capsulorhexis in four cases (13.3%) and conversion to a conventional extraction technique in two cases. There were no cases of posterior capsular tear. Twenty-eight eyes (93.3%) had a final best corrected visual acuity at 8/10 or better. Postoperative complications included moderate transient corneal edema in six cases (20%) and iritis in three cases (10%). There were no complications related to the use of trypan blue.

Conclusion
Phacoemulsification using trypan blue was safe and effective in managing white cataract and had a high success rate.

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Ziakas NG, Boboridis K, Nakos E, Mikropoulos D, Margaritis V, Konstas AGP (2009):

DOES THE USE OF TRYPAN BLUE DURING PHACOEMULSIFICATION AFFECT THE INTRAOCULAR PRESSURE?

Can J Ophthalmol 44, 293-296

OBJECTIVE:
The purpose of the study was to evaluate the effect of trypan blue on intraocular pressure (IOP) after small-incision cataract surgery.

DESIGN:
Prospective, randomized study.

PARTICIPANTS:
Fifteen patients (30 eyes) with bilateral, dense, age-related cataracts.

METHODS:
Patients with glaucoma, ocular hypertension, exfoliation, pigment dispersion syndrome, history of uveitis, recent use of topical or systemic steroids, and previous ocular surgery were excluded. The patients were randomly assigned to receive trypan blue during cataract surgery for enhancing capsulorrhexis in 1 of their eyes, while in the other eye, trypan blue was not used. Cataract surgery was performed in an identical fashion in both eyes, with a sutureless posterior limbal incision, phacoemulsification, and implantation of a foldable intraocular lens. The same viscoelastic (sodium hyaluronate) was used in all cases and was thoroughly aspirated at the end of the procedure. All patients received a single dose of 250 mg acetazolamide 8 hours after surgery. No other antiglaucomatous agent was used during surgery or postoperatively. The intraocular pressure (IOP) was measured preoperatively and at 24 hours, 1 week, 1 month, and 3 months postoperatively.

RESULTS:
IOP values were similar in both groups at all 4 postoperative measurements. There was no statistically significant difference in postoperative IOP values between the eyes in which trypan blue was used and the control eyes.

CONCLUSIONS:
The use of trypan blue during small-incision cataract surgery does not have any effect on IOP during the immediate and early postoperative period.

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mith EF, Desai RU, Schrier A, Enriquez B, Purewal BK (2010):

TRYPAN BLUE CAPSULORHEXIS.

Ophthalmology 117, 1462-1462.e1

Comment on
Capsule staining as an adjunct to cataract surgery: a report from the American Academy of Ophthalmology.

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Jaber R, Werner L, Fuller S, Kavoussi SC, McIntyre S, Burrow M, Mamalis N (2012):

COMPARISON OF CAPSULORHEXIS RESISTANCE TO TEARING WITH AND WITHOUT TRYPAN BLUE DYE USING A MECHANIZED TENSILE STRENGTH MODEL.

J Cataract Refract Surg 38, 507-512

PURPOSE:
To evaluate the influence of trypan blue staining on capsulorhexis tear resistance using a model for mechanical measurement of the entire capsular bag of fresh human cadaver eyes.

SETTING:
John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA.

DESIGN:
Experimental study.

METHODS:
After the cornea and iris were removed, a 5.0 to 5.5 mm anterior continuous curvilinear capsulorhexis (CCC) was created; the capsule in study eyes was stained with trypan blue. The nucleus was hydroexpressed and the capsular bag was evacuated by irrigation/aspiration. Two metal shoetree-shaped fixtures were implanted separately in the capsular bag and assembled using a screw nut. After zonulectomy, the fixture-capsular bag assembly was removed from the eye and loaded onto a mechanized tester. The fixtures were separated at a velocity of 7.0 mm/min in 0.15 μm intervals to stretch the capsulorhexis to its rupture point. A graph was generated for each eye.

RESULTS:
Ten study eyes were compared with 23 control eyes. The groups were comparable in donor age, time from death, and CCC diameter. The mean rupture load was 0.40 Newton (N) ± 0.13 (SD) in the trypan blue group and 0.39 ± 0.16 N in the control group (P=.94). The mean extension was 5.70 ± 0.99 mm and 5.85 ± 1.17 mm, respectively (P=.74).

CONCLUSIONS:
There was no difference in CCC strength between trypan blue-stained capsules and control capsules. Staining with trypan blue did not reduce CCC tear resistance.

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Giammaria D, Giannotti M, Scopelliti A, Pellegrini G, Giannotti B (2013):

UNDER-AIR STAINING OF THE ANTERIOR CAPSULE USING TRYPAN BLUE WITH A 30 G NEEDLE.

Clin Ophthalmol 7, 233-235

Abstract
The original technique of staining the anterior capsule of the lens with Trypan blue involves the injection of an air bubble in the anterior chamber. A drawback of this technique is the possible instability of the anterior chamber caused by the sudden exit of air when the dye is injected with the cannula through the side-port incision. Other staining techniques that use viscoelastic substances to increase the stability of the anterior chamber and to dose the injected dye have been described. The authors present an under-air staining technique of the anterior capsule using one drop of Trypan blue injected with a 30 G needle through the peripheral cornea. This procedure prevents the air bubble from escaping the anterior chamber and allows fast and selective staining of the capsule.

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