• Users Online: 257
  • Home
  • Print this page
  • Email this page

   Table of Contents      
Year : 2020  |  Volume : 68  |  Issue : 1  |  Page : 247-249

Combined brilliant blue G and xenon light induced outer retinal layer damage following macular hole surgery

Department of Retina and Vitreous, Narayana Nethralaya, Bengaluru, Karnataka, India

Date of Submission27-Jul-2019
Date of Acceptance17-Aug-2019
Date of Web Publication19-Dec-2019

Correspondence Address:
Dr. Ramesh Venkatesh
Department of Retina and Vitreous, Narayana Nethralaya, 121/C, Chord Road, 1st ‘R’ Block, Rajaji Nagar, Bengaluru - 560 010, Karnataka
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1386_19

Rights and Permissions

We report a case of combined brilliant blue G and endoilluminator retinal toxicity in a patient who has undergone macular hole surgery. The patient developed extensive degeneration of the retinal pigment epithelium as early as 1 week following surgery that eventually lead to poor visual outcome. We look into the pathogenesis of BBG and endoilluminator causing retinal toxicity and also suggest measures to avoid this irreversible retinal damage.

Keywords: BBG, macular hole, retinal damage, surgery, toxicity

How to cite this article:
Venkatesh R, Aseem A, Jain K, Yadav NK. Combined brilliant blue G and xenon light induced outer retinal layer damage following macular hole surgery. Indian J Ophthalmol 2020;68:247-9

How to cite this URL:
Venkatesh R, Aseem A, Jain K, Yadav NK. Combined brilliant blue G and xenon light induced outer retinal layer damage following macular hole surgery. Indian J Ophthalmol [serial online] 2020 [cited 2022 Sep 29];68:247-9. Available from: https://www.ijo.in/text.asp?2020/68/1/247/273192

Surgical management of a full-thickness macular hole (MH) requires vitrectomy with posterior hyaloid removal, stripping of internal limiting membrane (ILM), and gas tamponade.[1] The peeling of the ILM helps in relieving the tangential traction from the retina and also removes the scaffold for a possible recurrent epiretinal membrane. Vital dyes like indocyanine green, brilliant blue G (BBG) and bromophenol blue have a higher affinity to stain the ILM.[2] Studies have demonstrated the toxic effects of vital dyes, especially indocyanine green on the retinal cells.[3] Studies on BBG have shown promising safety profile compared to indocyanine green after subretinal and intravitreal injections.[2] BBG use showed better final visual and structural outcomes after surgery compared to indocyanine green.[4],[5] However, Ambiya et al. have reported reduction in the inner retinal layer thickness with use of BBG in MHs.[6] This case report describes an unusual case of macular outer retinal damage following vitreoretinal surgery for full thickness MH and explains the possible role of BBG and endoilluminator in this regard.

  Case Report Top

A 65-year-old woman presented to the retina clinic with decreased vision in the right eye for 1 month with visual acuity of 6/24, N18. Fundus examination through the hazy media due to cataract revealed a full thickness MH in the right eye. Left eye examination was normal. Spectral domain optical coherence tomography (OCT) using the Spectralis Heidelberg machine confirmed a full-thickness MH with intraretinal cystoid spaces. The minimum inner diameter and basal diameter of MH was 201 μ and 816 μ respectively along its long axis [Figure 1]a. Posterior vitreous detachment was present. Macular hole repair along with cataract surgery was recommended which she underwent 10 days after presentation.
Figure 1: Optical coherence tomography (OCT) and fundus autofluoroscence images of the right eye: (a) At presentation, there is a full thickness macular hole with intraretinal cystoid spaces and intact outer retinal layers in the right eye on OCT. (b) OCT image at 1.week post-surgery showing the damaged retinal pigment epithelial and outer retinal layers. (c) Similar OCT findings are noted at 3 weeks post-surgery. (d) Fundus autofluorescence of the right eye showing a well-defined area of mixed autofluoroscence pattern confirming the damaged outer retinal layers

Click here to view

A 25-gauge, 3-port pars plana vitrectomy using the Alcon, CONSTELLATION ® Vision System was performed. After core vitrectomy, intravitreal triamcinolone acetonide was injected to stain the posterior cortical vitreous. Posterior vitreous detachment was completed. Fluid air exchange was done. ILM was stained using BBG (Ocublue Plus 0.05%w/v, Aurolab) for a contact time of 2 minutes. After 2 minutes, excess BBG was removed passively with flute needle and saline infusion was started. Staining of the ILM seemed inadequate. No epiretinal membrane was visualised intraoperatively. ILM peeling was attempted using the disposable GRIESHABER ® asymmetrical forceps using the pinch-pick-peel technique. After multiple failed attempts to lift the ILM edge, it was decided to restain the ILM with BBG under air. Again, contact time of 2 minutes was given. Peeling of the ILM was achieved in a uniform manner. The ILM peel extended superiorly midway between the superior arcade and MH and inferiorly till the inferior arcade. The duration of ILM peeling was prolonged and the total surgery duration was 90 minutes. No other complications were noted intra-operatively. Repeat fluid air exchange was done and 20% sulphur hexafluoride gas was used for endotamponade and prone position was maintained for 7 days. On post-operative day 1, intraocular pressure was normal, retina attached, and the status of MH was difficult to comment. At 1-week follow-up, OCT showed type 1 MH closure with disrupted outer retinal layers [Figure 1]b. Residual gas bubble (30%) was present. At 3 weeks post-operative follow-up visit, OCT showed a closed MH with damaged outer retinal layers [Figure 1]c. Fundus autofluoroscence showed a well-defined area of hypo and hyper autofluoroscence [Figure 1]d. The best-corrected visual acuity deteriorated to 4/60. At 3 months post-surgery, the OCT still showed a type 1 MH closure and visual acuity of 4/60.

  Discussion Top

Retinal damage following MH surgery can occur due to surgical trauma while vitrectomy or ILM peeling,[7] toxicity due to the use of vital dyes like BBG or indocyanine green,[3],[4] phototoxicity due to the microscope light or endo illuminator [8] and toxicity due to the inappropriate antibiotic dose in the saline infusion. In this case, no intraoperative complications were noted, and antibiotics were not added to the infusion solution. The damage of the retinal layers in this case was noted primarily to the retinal pigment epithelial (RPE) cells and photoreceptors. The inner retinal layers were normal in structure.

The light absorption properties and emission spectrum of BBG lies between 260 and 900 nm in different solvents. All BBG solutions have double-peak curves. The first peak is noted at 260–280 nm and the second peak occur between 540 and 680 nm. Endoilluminator with wavelength ≥400 nm light induces phototoxic effects mainly in RPE.[9] The CONSTELLATION ® Vision System from Alcon uses the xenon light for endo illumination during the vitreoretinal surgeries. Xenon light has a peak wavelength of 450 nm (range 420–700 nm).[10] Vital dyes are small chemical molecules that easily penetrate retina and produces phototoxic free radicals due to changes in emission spectrum after absorption of light. The increased absorption of the xenon light by the BBG and changes in the emission spectra of BBG produces toxic free radicals and subsequent damage to the RPE cells and photoreceptors. In vitro studies on the human RPE cells (ARPE-19) have shown that RPE cell viability to reduce in the presence of BBG, focal high illumination used for >5 minutes and medium diffuse illumination used for >15 minutes, respectively.[8],[9] To the best of our knowledge, no report describing the RPE and photoreceptor damage following macular hole surgery due to cumulative BBG and xenon light toxicity has been noted in literature. In this case, stripping of the ILM became tedious due to the poor ILM staining. The cumulative damage caused to the RPE cells and photoreceptors due to the repeated use of BBG for longer time to stain the ILM and focal high illumination for longer periods to peel the ILM could have led to the poor visual outcome in this case.

  Conclusions Top

To conclude, a rare case of outer retinal damage following MH surgery due to repeated staining of ILM with BBG and use of high focal xenon light illumination has been described. This report educates the surgeon to be quick and precise while performing macular surgeries. One should avoid repeated staining of ILM with BBG and instead use BBG mixed with isotonic glucose solution at a concentration range of 2.5-10% for better ILM staining. Furthermore, one should avoid the use of high focal illumination close to the macula (<10 mm) to avoid any phototoxic damage to the RPE cells and photoreceptors.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Lois N, Burr J, Norrie J, Vale L, Cook J, McDonald A, et al. Internal limiting membrane peeling versus no peeling for idiopathic full-thickness macular hole: A pragmatic randomized controlled trial. Invest Ophthalmol Vis Sci 2011;52:1586-92.  Back to cited text no. 1
Hernández F, Alpizar-Alvarez N, Wu L. Chromovitrectomy: An update. J Ophthalmic Vis Res 2014;9:251-9.  Back to cited text no. 2
Gandorfer A, Haritoglou C, Kampik A. Toxicity of indocyanine green in vitreoretinal surgery. Dev Ophthalmol 2008;42:69-81.  Back to cited text no. 3
Baba T, Hagiwara A, Sato E, Arai M, Oshitari T, Yamamoto S. Comparison of vitrectomy with brilliant blue G or indocyanine green on retinal microstructure and function of eyes with macular hole. Ophthalmology 2012;119:2609-15.  Back to cited text no. 4
Williamson TH, Lee E. Idiopathic macular hole: Analysis of visual outcomes and the use of indocyanine green or brilliant blue for internal limiting membrane peel. Graefes Arch Clin Exp Ophthalmol 2014;252:395-400.  Back to cited text no. 5
Ambiya V, Goud A, Khodani M, Chhablani J. Inner retinal thinning after brilliant blue G-assisted internal limiting membrane peeling for vitreoretinal interface disorders. Int Ophthalmol 2017;37:401-8.  Back to cited text no. 6
Venkatesh R, Gurav P, Dave PA. Iatrogenic choroidal neovascular membrane in macular hole-induced retinal detachment. Retin Cases Brief Rep 2018;12:140-2.  Back to cited text no. 7
Balaiya S, Sambhav K, Cook WB, Chalam KV. Osmolarity and spectrophotometric property of brilliant blue green define the degree of toxicity on retinal pigment epithelial cells exposed to surgical endoilluminator. Clin Ophthalmol Auckl NZ 2016;10:1543-51.  Back to cited text no. 8
Gorgels TG, van Norren D. Ultraviolet and green light cause different types of damage in rat retina. Invest Ophthalmol Vis Sci 1995;36:851-63.  Back to cited text no. 9
Costa E de PF, Rodrigues EB, Farah ME, Dib E, Penha F, Magalhães O, et al. Vital dyes and light sources for chromovitrectomy: Comparative assessment of osmolarity, pH, and spectrophotometry. Invest Ophthalmol Vis Sci 2009;50:385-91.  Back to cited text no. 10


  [Figure 1]

This article has been cited by
1 Paclitaxel may be a risk factor for retinal phototoxicity
Jonathan Malcolm, Caroline Oi Lune Wong, Jared Ching, Shohista Saidkasimova
American Journal of Ophthalmology Case Reports. 2022; : 101292
[Pubmed] | [DOI]
2 Macular toxicity of vital dye after pars plana vitrectomy for idiopathic epiretinal membrane: A case report
Héloïse Torres-Villaros, Steven Louis-Philippe, Fatima Amari, Audrey Giocanti-Aurégan, Lucie Janicot
American Journal of Ophthalmology Case Reports. 2022; : 101588
[Pubmed] | [DOI]
3 Customized Color Settings of Digitally Assisted Vitreoretinal Surgery to Enable Use of Lower Dye Concentrations During Macular Surgery
Su Jin Park, Jae Rock Do, Jae Pil Shin, Dong Ho Park
Frontiers in Medicine. 2022; 8
[Pubmed] | [DOI]
4 Presumed Combined Brilliant Blue G and Endolight-Induced Macular Damage following Epiretinal Membrane Removal Surgery
Ramesh Venkatesh, Aditi Gupta, NareshKumar Yadav, Jay Chhablani
Journal of Current Ophthalmology. 2022; 34(2): 267
[Pubmed] | [DOI]
5 Diffuse retinal pigment epithelium atrophy following pars plana vitrectomy for high myopic macular hole assisted by Brilliant Blue G: A case report
Ortiz Federico, Bures-Jelstrup Anniken, Mateo Carlos
American Journal of Ophthalmology Case Reports. 2021; 23: 101148
[Pubmed] | [DOI]
6 The Influence of Crescent-Shaped Selective Internal Limiting Membrane Staining on Vital Dye Toxicity in Temporal Inverted Flap Technique
Remzi Avci, Aysegul Mavi Yildiz, Sami Yilmaz
Current Eye Research. 2021; 46(9): 1363
[Pubmed] | [DOI]
7 Brilliant Blue G toxicity in macular hole surgeries: A report on combined phototoxicity and dye-induced macular damage
Aniruddh Soni, Deepika C Parameswarappa, Mudit Tyagi, Niroj K Sahoo, Avantika Dogra, Rajeev Reddy Pappuru, Jay Chhablani
Seminars in Ophthalmology. 2021; : 1
[Pubmed] | [DOI]
8 Long-Term Outcomes of Macular Hole Repair with Triamcinolone Acetonide Visualization
Josh Wallsh, Masumi G Asahi, Ron Gallemore
Clinical Ophthalmology. 2021; Volume 15: 1607
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Case Report
Article Figures

 Article Access Statistics
    PDF Downloaded158    
    Comments [Add]    
    Cited by others 8    

Recommend this journal