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LETTER TO EDITOR
Year : 2004  |  Volume : 52  |  Issue : 4  |  Page : 339

Differential staining with indocyanine green and trypan blue dye.



Correspondence Address:
A Kumar


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Source of Support: None, Conflict of Interest: None


PMID: 15693333

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How to cite this article:
Kumar A, Prakash G. Differential staining with indocyanine green and trypan blue dye. Indian J Ophthalmol 2004;52:339

How to cite this URL:
Kumar A, Prakash G. Differential staining with indocyanine green and trypan blue dye. Indian J Ophthalmol [serial online] 2004 [cited 2020 Jun 5];52:339. Available from: http://www.ijo.in/text.asp?2004/52/4/339/14554

Dear Editor,

Removal of overlying glial proliferation of epimacular membrane (EMM), and internal limiting membrane (ILM) provides one of the greatest challenges to the retinal surgeon during macular hole surgery. These membranes have a variable degree of adherence to the underlying retina, and the retina itself is often thin and atrophic. The uneven topography of the retina may be hidden beneath the opaque membrane, increasing the surgical complexity and risk.

We have been using differential staining of EMM with trypan blue (Blurhex, Dr. Agarwal's Pharma Ltd, Chennai, India) and ILM with indocyanine green (ICG-Pulsion®, Germany) dye for more than six months now. The contrast of blue against the underlying retina greatly facilitates the identification and removal of EMM as previously described.[1] Following vitrectomy and posterior vitreous separation, the undiluted trypan blue dye is squirted over the posterior pole and ports are closed for 5 minutes with the infusion canula turned off. After this, approximately 0.2 ml of sterile 0.5% ICG is squirted over the macula. The vitrectomy ports are temporarily plugged for about 2 minutes.[2] The excess ICG is aspirated from vitreous cavity with vitrector. A striking blue-stained EMM is visualised along with green-colored ILM.

Trypan blue is a vital dye and stains only the dead cells, while ICG is a supravital dye and stains only the live cells. The ILM consists of live cells and is therefore not stained by trypan blue. This differential staining is utilised by us for greater surgical ease. The two dyes can also be used sequentially, trypan blue initially for EMM removal and ICG later for ILM peeling.

An obvious edge of the EMM can be easily detected because of trypan blue staining. A "front" of elevated membrane is created, taking care not to fragment the membrane by pulling too hard or too long in any one direction, especially when near the fovea. Once the membrane has been lifted off from the posterior pole, it is removed from the eye using blunt-tipped vitreous forceps. Staining the EMM with trypan blue provides surgeons with a safe and effective way of visualising the EMM.

The ILM flap is created by gently rubbing the retina with the pic-forceps (Grieshaber) and then the flap is grasped with the same pic-forceps; a smooth-edged continuous tear is created by slowly tearing the ILM in a circular motion, concentric with the fovea, keeping the direction of force always following the natural course of the nerve fibres.

Trypan blue permits the surgeon to identify all the epiretinal tissue and ICG helps demarcate the ILM, [Figure - 1] ensuring a more complete peel in less time, which should improve the success rate and possibly minimise the chances for macular phototoxicity. Also, the incidence of persistent macular hole might be minimized.



 
  References Top

1.
Kumar A, Prakash G. Trypan blue enhanced epiretinal membrane peel in retinal detachment with proliferative vitreoretinopathy. Delhi J Ophthalmology 2003;9:42-44.  Back to cited text no. 1
    
2.
Kumar A, Prakash G, Singh RP. Indocyanine green enhanced maculorhexis in macular hole surgery. Indian J Ophthalmol 2002;50:123-26.  Back to cited text no. 2
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