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   Table of Contents      
Year : 2002  |  Volume : 50  |  Issue : 2  |  Page : 157-159

Anterior capsule staining. Techniques, recommendations and guidelines for surgeons

Correspondence Address:
Suresh K Pandey

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Source of Support: None, Conflict of Interest: None

PMID: 12194577

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How to cite this article:
Pandey SK, Werner L, Wilson M E, Izak AM, Apple DJ. Anterior capsule staining. Techniques, recommendations and guidelines for surgeons. Indian J Ophthalmol 2002;50:157-9

How to cite this URL:
Pandey SK, Werner L, Wilson M E, Izak AM, Apple DJ. Anterior capsule staining. Techniques, recommendations and guidelines for surgeons. Indian J Ophthalmol [serial online] 2002 [cited 2020 Oct 28];50:157-9. Available from: https://www.ijo.in/text.asp?2002/50/2/157/14800

  Dear Editor, Top

We congratulate Kothari, et al for their interesting article "Anterior capsule staining with trypan blue for capsulorhexis in mature and hypermature cataracts: A preliminary study".[1] The authors evaluated the efficacy and safety of 0.1% trypan blue dye to stain the anterior capsule for capsulorhexis in 25 cases (25 eyes) presenting with mature, hypermature or traumatic cataract. The authors did not observe any adverse effect related to the trypan-blue dye at the end of a mean follow-up period of 3 months. They concluded that staining of the anterior lens capsule with trypan-blue dye was a useful and safe technique for performing anterior capsulorhexis in mature and hypermature cataracts.

The capsular dyes (i.e. trypan blue, indocyanine green [ICG]) have also been used for enhanced visualisation in traumatic cataract.[1][2][3] During the last 3 years, we have extensively studied the use of non-toxic ophthalmic dyes (e.g., fluorescein sodium, ICG and trypan blue) to enhance visualisation of the anterior capsule while performing anterior continuous circular capsulorhexis (CCC).[4] We have also demonstrated the use of capsular dyes (0.5% ICG and 0.1% typan blue) to enhance visualisation while learning and performing other critical steps of the phacoemulsification procedure, including posterior capsulorhexis.[5][6][7][8][9] Posterior capsule staining can also be useful while learning and later performing the procedure in paediatric eyes, either manually or with vitrector.[6][7][8][9] Our experience in postmortem human eyes suggest that the residual lens cortex can also be stained to distinguish the feathery, irregular staining of residual subcapsular cortex from the smooth staining of the anterior, equatorial and posterior capsule [Figure - 1].[7] Thus, the staining facilitates cleaning of residual cortical matter from the capsular bag. More clinical studies are needed to reach definitive conclusions regarding staining of the lens cortex and its clinical applications for complete cleaning of the capsular bag.

We have compared two techniques for staining the anterior capsule when performing CCC: staining from above under an air bubble, and intracameral subcapsular injection of the dye with or without blue-light enhancement.[4] The former technique (staining under an air bubble) is currently used by most ophthalmic surgeons. Kothari and associates[1] observed uniform staining of the anterior lens capsule after use of a single, large air-bubble, rather than multiple small air-bubbles. Another benefit of this technique is the staining of the peripheral anterior rim, which is otherwise difficult to visualise during the phacoemulsification procedure. However, air in the anterior chamber makes it unsteady. An instrument entering the eye will cause some air to escape, with a rise of the lens-iris plane. A small amount of high-density viscoelastic placed near the incision can prevent an air bubble from escaping the anterior chamber, thus minimising the risk of a sudden collapse.

Alternatively, Akahoshi (Akahoshi T. Soft-shell stain technique for white cataract. ASCRS symposium on Cataract, IOL, and Refractive Surgery, Boston, MA, USA, May 2000) proposed a "soft-shell stain technique" when performing CCC in white cataract cases. A small amount of viscoelastic (Viscoat, Alcon Laboratories, Fort Worth, TX, USA) was injected into the anterior chamber followed by a high molecular-weight viscoelastic material (Provisc, Alcon Laboratories, Fort Worth, TX, USA) to fill the chamber completely. The author then injected the ICG solution on the lens surface with a bent 27-guage visco-cannula. The anterior capsule was uniformly stained green and easily visualised, while the cornea remained unstained. According to the author, the soft-shell stain technique is extremely useful for CCC in white cataracts. Alternatively, the dye solution can be mixed with visco elastic agents. Kayikicioglu and coworkers[10] proposed a technique for limiting contact of trypan blue with the cornea by mixing the dye with a viscoelastic solution. These researchers mixed 0.4% trypan blue with 1% sodium hyaluronate in a 2 mL syringe. The dye-viscoelastic solution was injected on to the anterior lens capsule, and it covered the anterior capsule without touching the corneal endothelium. There is a potential risk of corneal decompensation after intraocular use of self-mixed solutions; however, these authors did not report significant surgical or postoperative adverse effects.

Clinical experience with ICG and trypan blue for anterior capsule staining in mature white or brunescent cataracts was first compared and reported by David Chang, in two consecutive, non-randomised series of mature or brunescent cataracts.[11] The technique of dye injection under an air bubble was utilised. ICG dye was used in the first series, and trypan blue in a subsequent series. According to the author, both dyes provided consistently excellent visualisation and clinical results without any adverse effects. However, trypan blue created more intense and persistent staining and provided superior visualisation compared to the ICG dye.[11]

We would like to provide some recommendations and guidelines on the use of suitable ophthalmic dyes and anterior capsule staining techniques. These are based on our extensive research on dye-enhanced adult and paediatric cataract surgery, as well as published clinical reports from several other surgeons. Both ICG and trypan blue are currently preferred over fluorescein-sodium dye, due to better staining of the anterior capsule and the absence of vitreous leakage (higher molecular weight).[4] Both dyes provide excellent visualisation of the anterior capsule flap during CCC, without causing any toxic effect to the corneal endothelium. Trypan blue is less expensive compared to ICG. However, trypan blue should be avoided in fertile/pregnant women and in children due to possible teratogenic and/or mutagenic effects, as observed in animal studies.[12] Currently, 0.1% trypan blue is the concentration used by most surgeons.[12] Further studies may help determine the lowest concentration of the trypan-blue (e.g., 0.05%, 0.025%, 0.01%, etc.) that can be used to stain the anterior lens capsule in order to perform CCC. ICG remains a valuable alternative for children and pregnant females. Staining under the air bubble technique is safe, and therefore recommended for intumescent and hypermature cataract patients presenting with high intralenticular pressure and a fragile anterior lens capsule. Viscoelastic solutions can be used to visco-seal incision site in order to avoid escape of the air bubble, and minimise any anterior chamber fluctuations. Alternatively, mixing the dye with a viscoelastic solution may also be used for better anterior capsule staining, and to limit contact with adjacent ocular tissues.[10]

We would like to emphasize care when performing anterior capsule staining in vitrectomised patients during cataract surgery. Inadvertent staining of the posterior lens capsule may occur secondary to diffusion of dye into the vitreous cavity, thereby obscuring the red reflex.[13] However, the trypan blue molecule is large and under normal circumstances does not appear to cross the intact zonula ciliaris. It is likely that an intact anterior hyaloid face would prevent bulk of dye flow into the vitreous cavity. One should avoid using any ophthalmic dyes in cataract surgery combined with implantation of hydrophilic acrylic lenses having a high water content (>70%), as this can lead to permanent staining (discolouration) of the IOL. This discolouration may become associated with a decrease or alteration in the best-corrected visual acuity, and eventually require IOL explantation/exchange. We recently analyzed two AcquaTM hydrophilic acrylic lenses (Mediphacos, Belo Horizonte, MG, Brazil) explanted secondary to bluish discoloration after use of trypan blue dye.[14] This was confirmed in a postmortem human eye implanted with AcquaTM lens after the capsular bag was stained using 0/1% trypan-blue [Figure - 2].

In brief, use of non-toxic ophthalmic dyes for anterior capsule staining in advanced, white cataracts allows performance of a safe and successful CCC. The dyes can also be helpful when training residents in the techniques of CCC, and when performing CCC[15] in cases presenting with nebular and/or macular corneal opacity. As mentioned by Kothari et al.,[1] anterior capsule staining can also be useful when converting from a can-opener technique to CCC.

  References Top

Kothari K, Jain SS, Shah NJ. Anterior capsular staining with trypan blue in mature and hypermature cataracts: A preliminary study. Indian J Ophthalmol 2001;49:177-80.  Back to cited text no. 1
Newsom TH, Oetting TN. Indocyanine green staining in traumatic cataract. J Cataract Refract Surg 2000;26:1691-93.  Back to cited text no. 2
Sharma N, Pangtey MS, Dada VK. Experience with indocyanine green dye. J Cataract Refract Surg 2001;27:1342.  Back to cited text no. 3
Pandey SK, Werner L, Escobar-Gomez M, Roig-Melo EA, Apple DJ. Dye-enhanced cataract surgery. Part I. Anterior capsule staining for capsulorhexis in advanced/white cataracts. J Cataract Refract Surg 2000;26:1052-59.  Back to cited text no. 4
Werner L, Pandey SK, Escobar-Gomez M, Hoddinott DSM, Apple DJ. Dye-enhanced cataract surgery. Part II. An experimental study to learn and perform critical steps of phacoemulsification in human eyes obtained postmortem. J Cataract Refract Surg 2000;26:1060-65.  Back to cited text no. 5
Pandey SK, Werner L, Escobar-Gomez M, Werner LP, Apple DJ. Dye-enhanced cataract surgery. Part III. Staining of the posterior capsule to learn and perform posterior continuous curviliniear capsulorhexis. J Cataract Refract Surg 2000;26:1066-71.  Back to cited text no. 6
Pandey SK, Werner L, Apple DJ. Staining the anterior capsule. J Cataract Refract Surg 2001;27:647-48.  Back to cited text no. 7
Pandey SK, Werner L, Apple DJ, Werner LP, Izak AM, Trivedi RH. Update on dye-enhanced cataract surgery. In: Change DF, ed., Hyperguide Online Textbook of Ophthalmology, Thorofare, NJ: Slack, 2001: http://www.ophthalmic.hyperguide.com.  Back to cited text no. 8
Pandey SK, Werner L, Apple DJ, Wilson ME. Dye-enhanced pediatric cataract surgery. J Pediatr Ophthalmol Strabismus 2002.  Back to cited text no. 9
Kayikicioglu O, Erakgun T, Guler C. Trypan blue mixed with sodium hyaluronate for capsulorhexis. J Cataract Refract Surg 2001;27-970.  Back to cited text no. 10
hang DF. Capsule staining and mature cataracts: A comparison of indocyanine green and trypan blue dyes.Br J Ophthalmol 2000;84 (Video Report: http:// www.bjophthalmol.com)  Back to cited text no. 11
Melles GRJ, Waard PWT, Pameyer JH, Beekhuis WH. Trypan blue capsule staining in cataract surgery. J Cataract Refract Surg 1999;24:7-9.  Back to cited text no. 12
Birchall W, Raynor MK, Turner GS. Inadvertent staining of the posterior lens capsule with trypan blue dye during phacoemulsification. Arch Ophthalmol 2001;119:1082-83.  Back to cited text no. 13
Werner L, Apple DJ, Crema A, Izak AM, Pandey SK, Trivedi RH, Ma L. Permanent bluish discoloration of a hydrophilic intraocular lenses caused by intraoperative use of trypan blue. J Cataract Refract Surg 2002 (In press, July issue).  Back to cited text no. 14
Dada T, R15. ay M, Bhartiya P, Vajpayee RB. Trypan blue assisted capsulorhexis for trainee phacoemulsification surgeons. J Cataract Refract Surg 2002;28:575-76.  Back to cited text no. 15


  [Figure - 1], [Figure - 2]

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