7.
Blue Dying: Clinical Experience
Vincenzo Ferrara (Arona)
Purpose: The complete peeling of all the different layers of the vitreoretinal interface has
become routine for the majority of vitreoretinal surgeons in macular surgery. Different dyes
have been introduced to facilitate a complete, safer and faster peeling. In our Institution the
use of Indocyanine Green (ICG) was abandoned after the clinical experience of two cases of
retinal pigment epithelium (RPE) toxicity related to its intraoperative use.
Methods: Since the year 2002, 1240 eyes have been treated for macular pucker, macular hole,
edema following venous occlusions or diabetic macular edema. Two surgeons (V.F. V.B.) performed
standard three-port pars plana vitrectomy (20\23\25 gauges) with an Accurus® 800 CS
Surgical System. Light source were the Halogen lamp included into the machine or a Xenon
lamp (Alcon High Brightness Illuminator). A Sapphire 90 mm or a Bullet Shielded were used as
illumination probe (15 % energy setting for the Xenon lamp and 30 % for the Halogen). A single 0,2 ml Triamcinolone (IVT®
Intra Vitreal Triamcinolone, Sooft Italia SpA) injection was applied in most of cases for a better visualization of the posterior
hyaloid which was always removed by active suction. Therefore a 0,15 % solution of Trypan Blue (TB) (Membrane Blue®
D.O.R.C. International) was injected into a Bss filled eye with a complete washout after 20 seconds. In the last 6 months a
0,18 % solution of Brilliant Blue (BB) (Brilliant Peel® Fluoron, GMBH 0,25 mg) was used as alternative, following the same
procedure. There were no differences in the demographic and macular surface characteristics of the BB and TB groups. After
a complete washout of the dye the epiretinal membranes (ERM) and the internal limiting membrane (ILM) were peeled with
ILM forceps.
Results: Staining of ERM was clearly evident after a single injection of TB whereas the BB didn’t coloured them efficiently
even after several injections. On the contrary removal of ILM was easier after a single injection of BB comparing to repeated
injections of TB. No significant difference was noted in postoperative visual acuity recovery between the two groups considered.
Two accidental subretinal migration of TB happened due to a briskly injection. There were no cases of retinal or RPE
toxicity in both groups.
Conclusions: Blue–assisted vitrectomy represents a safe way to achieve a complete and safe removal of both cellular and
acellular membranes overlying the macula. In our experience the use of TB or BB lead to good anatomical and functional
results comparable with ICG without evidence of dye-related adverse effects. TB seems especially indicated for staining
epiretinal cellular membranes whereas the BB appears to be more effective for the staining and peeling of the acellular ILM.
Their specific indication for the intraocular surgery use seems an additional reason to prefer them to other ‘off-label’ solutions.