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Year : 2001  |  Volume : 49  |  Issue : 3  |  Page : 177-180

Anterior capsular staining with trypan blue for capsulorhexis in mature and hypermature cataracts. A preliminary study

1 MS. Bombay City Eye Institute, Mumbai, India
2 DNB. Bombay City Eye Institute, Mumbai, India

Correspondence Address:
Kulin Kothari
MS. Bombay City Eye Institute, Mumbai, India

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Source of Support: None, Conflict of Interest: None

PMID: 15887726

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Purpose: To study the efficacy and safety of 0.1% Trypan Blue dye to stain the anterior capsule for capsulorhexis in mature and hypermature cataracts.
Methods: This preliminary study included 25 eyes of 25 patients with a unilateral mature or hypermature cataract, including one case of traumatic mature cataract. In all these cases 0.2ml of 0.1% trypan blue dye was used to stain the anterior capsule. The efficacy and safety of the dye was evaluated on the basis of intraoperative and postoperative observations.
Results: In all 25 eyes the capsulorhexis was completed. There was peripheral extension of the capsulorhexis in the eye with traumatic cataract and the stained edge of the anterior capsule helped identification and redirection of the capsulorhexis. Successful phacoemulsification with intraocular lens implantation was performed in all eyes. Adverse reactions related to the dye such as raised intraocular pressure, anterior chamber inflammation and endothelial damage were not observed in the immediate postoperative period or at the end of mean follow-up of 3 months.
Conclusion: Trypan blue dye staining of the anterior capsule appears to be a very useful and safe technique that simplifies capsulorhexis in mature and hypermature cataracts.

Keywords: Cataract, mature cataract, hypermature cataract, capsulorhexis, trypan blue dye

How to cite this article:
Kothari K, Jain SS, Shah NJ. Anterior capsular staining with trypan blue for capsulorhexis in mature and hypermature cataracts. A preliminary study. Indian J Ophthalmol 2001;49:177-80

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Kothari K, Jain SS, Shah NJ. Anterior capsular staining with trypan blue for capsulorhexis in mature and hypermature cataracts. A preliminary study. Indian J Ophthalmol [serial online] 2001 [cited 2023 Dec 11];49:177-80. Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?2001/49/3/177/22632

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Phacoemulsification in hypermature and mature cataracts is challenging because of the technical difficulties encountered while performing continuous curvilinear capsulorhexis (CCC). Intumescence or raised intracapsular pressure (IOP) adds to the difficulty.[1] The CCC technique has improved significantly the safety of cataract extraction and in-the-bag intraocular lens (IOL) implantation. The red fundus reflex produced by coaxial light of the microscope is essential to visualize the capsule while performing capsulorhexis. Hence when this retroillumination is absent, such as in the mature and hypermature cataracts, it is difficult to identify the propagating edge of the capsulorhexis. There is considerable difficulty to distinguish the advancing edge of the anterior capsule from the underlying white lens matter. Inadequate visualisation of the capsule in such cases carries a high risk of peripheral extension of the advancing edge towards or beyond the lens equator with its attendant complications.[2] This can be obviated if the anterior capsule can be temporarily stained with any contrasting dye. We used 0.1% trypan blue to stain the anterior capsule for ease of visualisation during capsulorhexis in mature and/or hypermature cataract. Concurrently we studied the efficacy and safety of use of this vital dye in the operated eye.

  Materials and Methods Top

This prospective study comprised 25 eyes of 25 patients who had unilateral senile mature or hypermature cataract including one patient with unilateral traumatic mature cataract. Preoperative visual acuity in each patient was light perception with accurate projection. Mean follow-up period was 3 months (range 2-4 months). In addition to routine preoperative work up for cataract extraction, specular microscopy and ultrasound B-scan examination were done to document preoperative endothelial status and to rule out any posterior segment pathology respectively.

All surgeries were pperformed by a single surgeon[KK] using peribulbar lidocaine anaesthesia through a two-step clear corneal incision. Prior to the incision a side port was made using a MVR blade. Through the side port incision, the anterior chamber was completely filled with air. Through a 27-gauge cannula, 0.2 ml of 0.1% trypan blue (Visionblueâ, D.O.R.C., Zuidland, Netherlands) was injected into the anterior chamber. After 5-10 seconds, the anterior chamber was thoroughly irrigated with balanced salt solution (BSS) to wash out the excess dye [Figure - 1]. High viscosity sodium hyaluronate[Healon GV™, Pharmacia] was injected into the anterior chamber to counter the effects of raised IOP. Capsulorhexis was performed with a modified Utrata forceps. Because of the blue stain of the anterior capsule, the outline of the capsulorhexis was clearly visible; this could easily be distinguished from the underlying grayish-white lenticular tissue [Figure - 2]. The "stop-and-chop" technique of phacoemulsification was used in all the cases and throughout the surgical procedure, the view was not hampered.

In the patient with traumatic cataract there was a pre-existing sutured corneal tear with iris adherent to a rent in the anterior capsule. The edges of the rent were fibrosed. Vannas scissors were used to cut this fibrosed edge to initiate the capsulorhexis. Intumescent swelling of the lens in the same patient resulted in an unintended extension of the capsulorhexis towards the periphery. Due to the stained edge this peripheral extension could be detected early. Deepening the anterior chamber with viscoelastic, and using the Vannas scissors to cut the capsule helped redirect and complete the capsulorhexis.

Two hours postoperatively, residual staining of the anterior capsule and the side port incision was seen faintly in all the cases. Subsequently, the patients were examined on day 1, 7 and at the end of 1 and 3 months postoperatively. At every visit, visual acuity assessment, slitlamp biomicroscopy, (with special emphasis on anterior chamber reaction) IOP measurement and fundus evaluation were done. Specular microscopy (Konan-Noncon Robopachy, Konan Medical Inc., Japan) was performed pre-operatively and at 3 months postoperatively. Evaluation of the safety of the dye was performed on the basis of intraoperative and postoperative observations.

  Results Top

In this study, this technique was used in 24 patients with mature and hypermature senile cataract and one patient with a traumatic mature cataract. Twenty-three patients were men, and the age range was 44 - 84 years (mean 59.2 ± 10.6 years)

In all 25 patients, the capsulorhexis was completed. Successful phacoemulsification and in-the-bag IOL implantation was performed in all cases. Time required to perform phacoemulsification ranged from 1.0 to 3.5 minutes (2.5 ± 0.7 minutes). No intraoperative complications were encountered. The intraoperative observations indicating the safety of the dye were: the dye could be easily washed out with BSS; the dye stained only the anterior capsule ; and it did not hamper the surgical view through the microscope during phacoemulsification either by coating the endothelium or by causing corneal haze.

On the first postoperative day, visual acuity ranged from 6/6 to 6/18. Slitlamp examination did not show residual staining of the anterior capsule. Five eyes (20%) had corneal oedema localised to the area of the incision which resolved at the end of one week. The anterior chamber reaction, ranging from 1+ to 2+ cells and 0 to 1+ flare; this subsided at the end of one week with topical 1% prednisolone acetate. None of the eyes had raised IOP postoperatively. At the end of 1 month all eyes had a best corrected visual acuity of 6/6.

All these patients were followed up for a mean period of 3 months. Specular microscopy at the end of 3 months showed a mean endothelial cell loss of 8.5%. Changes in endothelial cell density and morphology are as shown in [Table - 1]. Thus, intra-or postoperative adverse effects from the use of trypan blue dye were not observed.

  Discussion Top

Mature and hypermature cataracts constitute a significant volume of the cataract surgical load in ophthalmic practice in developing countries. CCC and emulsification of hard nucleus are the two steps that make phacoemulsification difficult in these cases. A number of methods have been described in the past decade to enhance the visualisation of the anterior capsule during CCC in advanced, white, intumescent, or hypermature cataracts. These include both non-staining [1,3-9] and staining methods[10-15] [Table - 2].

Trypan blue, a vital stain, is taken up only by dead or damaged endothelial cells, and the normal cells remain unstained. Use of 0.5% trypan blue was described in the literature in 1966,[16] and the clinical safety was proved in 1970.[17] It was initially suggested as a simple, practical, and safe method for evaluating donor corneas prior to grafting. Harmful effects on endothelium were not observed either in experimental tests and clinical trials. 0.1% trypan blue has been used clinically to examine endothelial cell damage after cataract extraction without adverse effects even at 8 years of follow-up.[18] Trypan blue 0.3% is also routinely used to examine the endothelial cell layer of the donor corneoscleral buttons prior to corneal transplantation at the Dutch National Eye Bank[19] and endothelial toxicity is not reported in 32,000 organ cultured corneas. Hence, when used in a concentration of 0.1%, trypan blue is unlikely to cause any toxicity to the endothelium or other intraocular structures. The chances are less likely since the excess dye can be washed out soon after it is applied to the lens capsule.

In our study, quick and homogeneous staining of the anterior capsule was obtained in all cases. We observed that a uniform large single air bubble is essential for staining of the anterior capsule. Multiple, small air bubbles cause irregular staining of the anterior capsule. The air in the anterior chamber causes the dye to spread over the anterior capsule, bordered by the pupillary rim of the iris, thus preventing a direct endothelial contact. The air also prevents dilution of the dye by the aqueous[15] so that the lowest effective concentration could be used.

As observed in one of our patients with traumatic cataract, intumescent swelling of the lens tends to cause an unintended extension of the capsulorhexis towards the periphery. This peripheral extension can be detected immediately and easily since the stained capsular edge is visualised throughout the act of capsulorhexis. To neutralise the radial centrifugal forces with the tractional vector forces, and prevent the progression of the tear towards equator, it is good practice to deepen the anterior chamber with high-viscosity sodium hyaluronate. [20,21] Sodium hyaluronate by virtue of its properties of cohesiveness, high viscosity, zero shear rate, and high molecular weight maintains the anterior chamber very well. It also has a low tendency of escaping from anterior chamber, allowing the surgeon to perform CCC with no appreciable variation in chamber depth.

In hypermature cataracts, escape of the milky cortex on the nicking of anterior capsule did not affect the staining of the capsule. In such cases we removed as much of the milky cortex as possible before proceeding with the capsulorhexis. An additional benefit of staining the anterior capsule with trypan blue was that the peripheral anterior capsule rim remained clearly visible during phacoemulsification. This is advantageous and helps avoid damage to the capsule by the phacotip in cases with capsulorhexis of small diameter or in those with small pupils. As an additional advantage it also aids in-the-bag IOL placement. Apart from assisting in visualisation of rhexis in mature and hypermature cataracts, this technique can also be utilised by surgeons who plan to convert their technique of capsulotomy from can-opener type to capsulorhexis.

Intraoperatively this dye was easily washed out with BSS. It stained only the anterior capsule and did not hamper the surgical view while performing phacoemulsification either by coating the endothelium or by causing corneal haze. There was no anterior chamber inflammation, rise in IOP and endothelial damage postoperatively. In conclusion, use of trypan blue is a useful and safe technique, which simplifies capsulorhexis in mature and hypermature cataracts.

  References Top

Vasavada A, Singh R, Desai J. Phacoemulsification of white mature cataracts. J Cataract Refrac Surg 1998;24:270-77.  Back to cited text no. 1
Gimble HV, Neuhann T. Development, advantages, and methods of the continuous circular capsulorhexis technique. J Cataract Refrac Surg 1990;16:31-37.  Back to cited text no. 2
Hausmann N, Richard G. Investigations on diathermy for anterior capsulotomy. Invest Ophthalmol Vis Sci 1991;32:2155-59.  Back to cited text no. 3
Krag S, Thim K, Corydon L. Diathermic capsulotomy versus capsulorhexis: A biochemical study. J Cataract Refrac Surg 1997;23:86-90.  Back to cited text no. 4
Brusini P. Capsulorhexis in mature cataracts: why not? Doc Ophthalmol 1992;81:281-84.  Back to cited text no. 5
Mansour AM. Anterior capsulorhexis in hypermature cataracts (letter). J Cataract Refract Surg 1993;19:116-17.  Back to cited text no. 6
Gimble HV. Two stage capsulorhexis for endocapsular phacoemulsification. J Cataract Refract Surg 1990;16:246-49.  Back to cited text no. 7
Chakarabati A, Singh S, Krishnadas R. Phacoemulsification in eyes with white cataract. J Cataract Refract Surg 2000;26:1041-47.  Back to cited text no. 8
Vajpayee RB, Angra SK, Honavar SG, Katoch S, Prasad N, Bansal A, et. al. Capsulotomy for phacoemulsification in hypermature cataracts. J Cataract Refract Surg 1995;21:612-15.  Back to cited text no. 9
Hoffer Kj, McFarland JE. Intracameral subcapsular fluorescein staining for improved visualisation during capsulorhexis in mature cataracts[letter]. J Cataract Refract Surg 1993;19:566.  Back to cited text no. 10
Fritz WL. Fluorescein blue, light-assisted capsulorhexis for mature or hypermature cataract. J Cataract Refract Surg 1998;24:19-20.  Back to cited text no. 11
Cimetta DJ, Gatti M, Lobianco G. Haemocoloration of the anterior capsule in white cataract CCC. Eur J Implant Refract Surg 1995;7:184-85.  Back to cited text no. 12
Horiguchi M, Miyake K, Ohta I, Ito Y. Staining of the lens capsule for circular continuous capsulorhexis in eyes with white cataract. Arch Ophthalmol 1998;116:535-37  Back to cited text no. 13
Pandey KS, Werner L, Escobar-Gomez M, Roig-Melo EA, Apple DJ. Dye- enhanced cataract surgery Part 1: Anterior capsule staining for capsulorhexis in advanced / white cataract. J Cataract Refract Surg 2000;26:1052-59.  Back to cited text no. 14
Melles GRJ, de Waard PWT, Pameyer JH, Beekhuis WH. Trypan blue capsule staining to visualise the capsulorhexis in cataract surgery. J Cataract Refract Surg 1999;25:7-9.  Back to cited text no. 15
Stocker FW, King EH, Lucas DO. A comparision of two different staining methods for evaluating corneal endothelial viability. Arch Ophthalmol 1966;76:833-35.  Back to cited text no. 16
Stocker FW, King EH, Lucas DO, Georgiade NA, Durham NC. Clinical test for evaluating donor corneas. Arch Ophthalmol 1970;84:2-7.  Back to cited text no. 17
Norn MS. Per operative trypan blue vital staining of corneal endothelium; Eight years' followup. Acta Ophthalmol 1980;58:550-55.  Back to cited text no. 18
Pels L, Schuchard Y. Organ culture in the Netherlands. Preservation and endothelial evaluation, In: Brightbill FS, editor, Corneal Surgery; Theory, Technique, and Tissue. St. Louis: CV Mosby Co, 1993;622-32.  Back to cited text no. 19
Caporossi A, Baiocchi S, Frezzotti P. Capsulorhexis: Principles and Techniques. In : Buratto L, editor. Phacoemulsification : Principles and Techniques. NJ, Slack Incorporated,, 1998;321-32.  Back to cited text no. 20
Arshinoff S. Mechanism of capsulorhexis. J Cataract Refract Surg 1992;18(6):623-28.  Back to cited text no. 21


  [Figure - 1], [Figure - 2]

  [Table - 1], [Table - 2]

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