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Anterior capsule staining using 0.025% trypan blue in all phacoemulsification cataract surgeries.

INTRODUCTION: The anterior capsulorhexis is resistant to radial tears during the various surgical steps and also offers the advantages of in the bag intraocular lens (IOL) implantation. Another advantage of capsulorhexis is the opportunity of a safe sulcus IOL implantation over the anterior capsule rim in cases of a posterior capsule rent. For a good control when performing a capsulorhexis, the visualisation of the anterior capsular flap margin is necessary and the lack of an adequate red reflex renders the technique very difficult. Many techniques have been proposed to help the surgeon to perform a capsulorhexis in cataracts without red reflex. The purpose of this report is to describe the use of 0.025% trypan blue solution to allow better anterior capsular flap visibility and a safe capsulorhexis in cataracts without red reflex.

METHODS: Thirty eyes of 30 patients with cataracts being the main casue of defective vision and no other known ocular disease were submitted to phacoemulsification and IOL implantation. The ages varied between 52 and 79 years (mean 68). All surgeries were done by the same surgeon (VDK), using the same equipment (Laureatte--Bausch & Laumb), under peribulbar anaesthesia, with a three plane clear corneal incision, the "stop and chop" technique and an implant with a 5.25 mm optical zone.

After the ancillary paracentesis, made in the limbus 70 to 90[degrees] away from the area where the clear cornea incision should be done, 0.2 to 0.5 ml of 0.025% trypan blue was injected in the anterior chamber, followed by filling of the anterior chamber with a viscoelastic solution, leaving the anterior capsule with a faint blue coloration. After the clear corneal incision, Anterior casulorhexis was performed using the 26G needle through the side port 2 clock hours away from the inferotemporal end of the superotemporal phacotunnel. The 0.025% trypan blue solution was obtained by diluting 0.1 ml of the 0.1% commercially available solution in 0.3 ml of Ringer lactate solution. The total effective used ultrasound power was recorded for each case. All patients had visual acuity, intraocular pressure (IOP) and anterior chamber reaction evaluated before surgery and on days 1, 6, 30 and 40 postoperatively.

RESULTS: Anterior capsulorhexis was successfully performed in all eyes. In two of them it was necessary to inject more viscoelastic after the initial capsular puncture because of liquefied cortical material leakage. The contrast between the stained capsular flap and the white cortical material allowed a safe control of the anterior capsulorhexis progression and the remaining anterior capsule edge was still stained during phacoemulsification. By the time of cortical aspiration, the faint blue coloration had disappeared from the anterior capsule rim. The remaining surgical steps were uneventful. On the first postoperative day, mild corneal stromal edema was seen in one eye and moderate edema in five eyes. By the 6th postoperative day the edema had vanished in all cases. There was no increase in IOP or any evidence of residual stain in the anterior segment during the postoperative period. The visual acuity, IOP and endothelial cell count before surgery and on day 40 are showed in Table 1. The endothelial cell loss varied between 1.37 to 6.67% (mean of 3.90%).

DISCUSSION: Many techniques have been suggested to improve safety in anterior capsulorhexis confection of cataracts without red reflex, such as the use of a optic fiber endoilluminator in a lateral position, endodiathermy, air filling of the anterior chamber, two step anterior capsulorhexis under high magnification, autologous blood impregnation and the injection of various vital stains in the anterior chamber like a solution of gentian violet and methylene blue, brilliant cresyl blue, fluorescein, trypan blue 0.1% and indocyanine green. Anionic (acidic) dyes such as trypan blue are less injurious to ocular tissue than cationic (basic) dyes. The endoilluminator and the endodiathermy imply in additional costs with sophisticated devices, and the endodiathermy capsulotomy is considered weaker than the traditional CCC. The two-step anterior capsulorhexis involves a change in the emulsification technique to work within a small anterior capsulorhexis and the additional risk of a radial tear or peripheral escape during the enlargement of the primary anterior capsulorhexis.

Trypan blue was decide to be used for all the patients because the deem outcome as well as proceeding with phacoemulsification depended on a good capsulorhexis. During cataract surgery, it (1) enhances capsular visualization for the safe completion of the capsulorhexis (the critical step in cataract surgery); (2) stains the anterior capsule, highlights the capsulorhexis, and provides a landmark during the remainder of the procedure; and (3) helps surgeons achieve a perfectly centered capsulorhexis that overlaps the IOL's optic by 0.5 to 1 mm or to create a "re-rhexis" in cases of severe capsular phimosis. Apart from issues relating to decentration, a perfect capsulorhexis may be a critical determinant of final IOL power, because the IOL's final position in the capsular bag is determined in part by the size of the capsulorhexis. A visible rhexis margin can prevent inadvertent damage during nuclear emulsification, such as phacoemulsification of the anterior capsular edge or passage of the chopper on top of the anterior capsule.

Among the vital stains, brilliant cresyl blue has never been used in vivo; the gentian violet and methylene blue solutions result in corneal edema and endothelial decompensation, fluorescein must be injected underneath the anterior capsule, staining the lens epithelium, not the capsule itself and it can stain the cornea and lens cortex also. Indocyanine green seems to be a good option, but it is expensive, not available in a fractionated fashion, has a life span of only 8 hours after dilution and must be kept protected from light.

Trypan blue is a vital stain classically used to evaluate damaged endothelial cells, presenting no toxicity in concentrations as high as 0.3%. Since it does not stain the healthy endothelial cells, it poses no risk of lowering intraoperative visibility. The safety of intraoperative use of trypan blue in extracapsular cataract surgery has already been proved with follow-up periods up to 8 years. Trypan blue provides several advantages in cataract surgery.

The rate of conversion to an extracapsular cataract extraction in white cataract as the result of an incomplete Capsulorhexis has been as low as 3.85% when Trypan Blue is used compared with 28.3%, when no dye has been used. Trypan Blue use has also been described to stain the leading edge of a lost capsulorhexis. Recently Melles et al. reported the use of 0.1% trypan blue to perform CCC in cataracts without red reflex. They advocated the use of an air bubble in the anterior chamber with injection of the stain between the air and the anterior capsule to prevent its dilution. We used the injection of a 0.025% solution without an air bubble in the chamber and achieved sufficient capsular staining. Injecting the dye between an air bubble and the capsule is not a easy maneuver and the size of the bubble is critical, since it can prevent the complete staining of the anterior capsule. Anterior capsulorhexis was safely performed with postoperative corneal findings similar to those usually seen in surgeries without it. Additionally, using a solution that is diluted starting from its original commercial presentation, without performance decay, represents a cost reduction that is an important goal of present phacoemulsification. Another possible application of capsular staining is in the training of new surgeons, since the improvement in flap visibility may help to control its progression for beginners even when the cataract has a good red reflex.


(1.) Hoffer KJ, McFarland JE. Intracameral subcapsular fluorescein staining for improved visualization during capsulorhexis in mature cataracts [letter]. J Cataract Refract Surg 1993;19:566.

(2.) Horiguchi M, Miyake K, Ohta I, Ito Y. Staining of the Lens Capsule for Circular Continuous Capsulorhexis in Eyes With White Cataract. Archives of Ophthalmology 1998;116:535-7.

(3.) Cimetta DJ, Gatti M, Labianco G. Hemocoloration of the anterior capsule in white cataract CCC. Eur J Implant Refract Surg 1995;7:184-5.

(4.) Melles GR, de Waard PW, Pameyer JH, Houdijn Beekhuis W. Trypan blue capsule staining to visualize the capsulorhexis in cataract surgery. J Cataract Refract Surg 1999;25:7-9.

(5.) Norn MS. Per operative trypan blue vital staining of corneal endothelium. Eight years' follow up. Acta Ophthalmol (Copenh) 1980;58:550-5.

(6.) Koch S, Katzen LE. Stop and chop phacoemulsification. J Cataract Refract Surg 1994;20:566-70.

(7.) Chang DF. Capsule staining and mature cataracts: a comparison of indocyanine green and trypan blue dyes. Br J Ophthalmol. 2000;84:809-936.

(8.) Sturmer J. [Cataract surgery and the "Blue Miracle"]. Klin Monatsbl Augenheilkd. 2002;219:191-195.

(9.) Ozturk F, Osher RH. Capsular staining: recent developments. Curr Opin Ophthalmol. 2006;17:42-44.

(10.) Jacobs DS, Cox TA, Wagoner MD, et al. Capsule staining as an adjunct to cataract surgery: a report from the American Academy of Ophthalmology. Ophthalmology. 2006;113:707-713.

(11.) Goldman JM, Karp CL. Adjunct devices for managing challenging cases in cataract surgery: capsular staining and ophthalmic viscosurgical devices. Curr Opin Ophthalmol. 2007;18:52 57.

(12.) San Laureano J, Coroneo MT. Crystalline lens capsule staining with trypan blue. J Cataract Refract Surg. 2004;30:2046-2049.

(13.) Coroneo M. Retrospective on staining with trypan blue. Cataract & Refractive Surgery Today. 2005;5:3:49-51.

(14.) Birchall W, Raynor MK, Turner GS. Inadvertent staining of the posterior lens capsule with trypan blue dye during phacoemulsification. Arch Ophthalmol. 2001;119:1082-1083.

(15.) Marques DM, Marques FF, Osher RH. Three-step technique for staining the anterior lens capsule with indocyanine green or trypan blue. J Cataract Refract Surg. 2004;30:13-16.

(16.) Arora R, Shroff D, Chauhan D, Narula R. Trypan-blue-assisted "re-rhexis" for smooth in-the-bag exchange of a calcified intraocular lens. J Cataract Refract Surg. 2006;32:215.

(17.) Cekic O, Batman C. The relationship between capsulorhexis size and anterior chamber depth relation. Ophthalmic Surg Lasers. 1999;30:185-190. [Erratum in: Ophthalmic Surg Lasers. 1999;30:714.]

(18.) Norn MS. Per operative trypan blue vital staining of corneal endothelium. Eight years' follow up. Acta Ophthalmol (Copenh). 1980;58:550-555.

(19.) Wollensak G, Sporl E, Pham DT. Biomechanical changes in the anterior lens capsule after trypan blue staining. J Cataract Refract Surg. 2004 ;30:1526-11530.

(20.) Coroneo MT, Pandey SK. Capsulorhexis integrity is unaffected by trypan blue: an in vitro study in human eyebank eyes. Poster presented at: The ARVO Annual Meeting. April 30, 2007; Fort Lauderdale, FL.

(21.) Hisatomi T, Enaida H, Matsumoto H, et al. Staining ability and biocompatibility of brilliant blue G: preclinical study of brilliant blue G as an adjunct for capsular staining. Arch Ophthalmol. 2006;124:514-519.

(22.) van Dooren BT, de Waard PW, Poort-van Nouhuys H, et al. Corneal endothelial cell density after trypan blue capsule staining in cataract surgery. J Cataract Refract Surg. 2002;28:574-675.

(23.) Werner L, Apple DJ, Crema AS, et al. Permanent blue discoloration of a hydrogel intraocular lens by intraoperative trypan blue. J Cataract Refract Surg. 2002;28:1279-1286.

(24.) Mamalis N, Edelhauser HF, Dawson DG, et al. Toxic anterior segment syndrome. J Cataract Refract Surg. 2006;32:324-333.

(25.) Wu L, Velasquez R, Montoya O. Non-infectious endophthalmitis associated with trypan blue use in cataract surgery. Int Ophthalmol. 2007;Jul 19 [E-pub ahead of print].

(26.) Morel PC, Roubi N, Talon DR, Bertrand X. Contamination of trypan blue with Burkholderia cepacia in a cornea bank. Infect Control Hosp Epidemiol.2003;24:198-201.


[1.] V.D. Karthigeyan


[1.] Consultant, Department of Ophthalmology, Hindu Mission Hospital, Chennai


Dr V.D Kartigeyan 16B, TKC Street, New Perungalathur, Chennai 63.

Date of Submission: 30/10/2013.

Date of Peer Review: 31/10/2013.

Date of Acceptance: 12/11/2013.

Date of Publishing: 19/11/2013



                                                              LOSS %

1        CF 3M     6/6      16       12      2791     2654     1.37
2        CF 4M     6/6      12       12      2492     1980     5.12
3         HM       6/6      18       14      2398     2211     1.87
4        CF3M     6/12      14       16      2428     2383     1.45
5        CF 4M     6/9      12       12      2460     2200     2.60
6        CF3M      6/9      14       12      2392     2180     2.12
7        CF 1M     6/6      16       14      2402     2100     3.02
8        CF 2M     6/9      12       12      2386     2066     3.20
9        CF3M      6/6      18       14      2478     2062     4.16
10        HM       6/9      16       14      2492     2020     4.72
11       CF 4M    6/12      12       16      2611     2100     5.11
12       CF3M      6/6      12       16      2511     2030     4.81
13       CF 2M     6/6      16       16      2486     2040     4.46
14       CF 4M     6/6      16       12      2391     2021     3.70
15       CF 1M    6/12      16       12      2532     1970     5.62
16       CF3M      6/6      12       14      2564     2010     5.54
17       CF 2M     6/6      16       12      2480     2380     5.12
18       CF 4M     6/6      16       14      2472     1968     5.58
19       CF3M      6/6      16       14      2478     2308     1.70
20       CF 1M     6/6      18       16      2566     1955     6.11
21       CF 2M     6/6      16       16      2671     2282     3.89
22       CF3M      6/6      16       12      2677     2018     6.59
23       CF 4M     6/6      16       16      2741     2074     6.67
24        HM       6/6      12       14      2712     2190     5.22
25       CF 1M    6/12      16       16      2681     2076     6.05
26       CF3M      6/9      16       16      2460     2082     3.78
27       CF 1M     6/9      16       16      2562     2030     5.32
28       CF 4M     6/9      12       14      2967     2392     5.75
29       CF3M      6/9      14       14      2328     2084     2.44
30       CF 1M    6/12      14       14      2489     2049     4.40

CF--counting fingers

HM--hand movements close to face


Intraocular pressure--recorded with applanation tonometer in mm hg
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Author:Karthigeyan, V.D.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Clinical report
Geographic Code:9INDI
Date:Nov 25, 2013
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