EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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EW CATARACT 21 December 2014 7. Katai N, Yokoyama R, Yoshimura N. Progressive brown discoloration of silicone intraocular lenses after vitrectomy in a patient on amiodarone. J Cataract Refract Surg. Mar 1999;25(3):451–452. 8. Jones DF, Irwin AE. Discoloration of intra- ocular lens subsequent to rifabutin use. Arch Ophthalmol. Sep 2002;120(9):1211–1212. 9. Mamalis N, Edelhauser HF, Dawson DG, Chew J, LeBoyer RM, Werner L. Toxic anterior segment syndrome. J Cataract Refract Surg. Feb 2006;32(2):324–333. 10. Melles GR, de Waard PW, Pameyer JH, Houdijn Beekhuis W. Trypan blue capsule staining to visualize the capsulorhexis in cataract surgery. J Cataract Refract Surg. Jan 1999;25(1):7–9. 11. Nour A. Efficacy of methylene blue dye in localization of sentinel lymph node in breast cancer patients. Breast J. Sep–Oct 2004;10(5):388–391. Editors' note: Drs. Kramer, Mamalis, and Werner are affiliated with the John A. Moran Eye Center, University of Utah, Salt Lake City. They have no financial interests related to this article. Contact information Kramer: gregory.kramer@utah.edu Mamalis: nick.mamalis@hsc.utah.edu Werner: liliana.werner@hsc.utah.edu corneal edema suggests the diagno- sis of TASS. Gradual improvement with steroids also suggests TASS. The presence of severe postop- erative anterior segment inflamma- tion also suggests the possibility of bacterial endophthalmitis. However, bacterial endophthalmitis typical- ly occurs 4 to 7 days after cataract surgery and presents with vitreous involvement and pain. EW References 1. Stevens S, Werner L, Mamalis N. Corneal edema and permanent blue discoloration of a silicone intraocular lens by methylene blue. Ophthalmic Surg Lasers Imaging. Mar–Apr 2007;38(2):136–141. 2. Hilgert CR, Hilgert A, Hofling-Lima AL, Farah ME, Werner L. Early opacification of SI-40NB silicone intraocular lenses. J Cataract Refract Surg. Oct 2004;30(10):2225–2229. 3. Tanaka T, Saika S, Hashizume N, Ohnishi Y. Brown haze in an Allergan SI-40NB silicone intraocular lens. J Cataract Refract Surg. Jan 2004;30(1):250–252. 4. AT M. Silicone intraocular lens implant in humans. Arch Ophthalmol. 1991;109:913–915. 5. Legler UF, Apple DJ. Comments on silicone intraocular lens discoloration. Arch Ophthalmol. Nov 1991;109(11):1495–1496. 6. Watt RH. Discoloration of a silicone intraocular lens 6 weeks after surgery. Arch Ophthalmol. Nov 1991;109(11):1494–1495. edema. 10 Similarly, the case that we describe demonstrates the potential for intraocular methylene blue to cause ocular toxicity. Methylene blue is a dye used in the diagnosis and treatment of multiple medical conditions. In the operating room, it is routinely used during breast cancer surgery to lo- calize sentinel nodes. 11 Trypan blue is a dye used in cataract surgery to enhance visualization of the anterior capsule during capsulorhexis and was approved by the FDA for this purpose in 2004. The widespread availability of methylene blue in the operating room and the similarity in name and color to trypan blue may lead to confusion. Cataract surgeons should be aware of the po- tential for methylene blue to result in ocular toxicity. Due diligence is necessary to ensure that the correct dye is used during cataract surgery. Moreover, surgeons should always keep in mind that any solution to be injected inside of the eye should have characteristics such as pH, os- molarity, and chemical composition adapted for intraocular use. Differential diagnosis The acute onset of anterior segment inflammation within 24 hours of cataract surgery and diffuse Centralized brown discoloration has been documented later in the postoperative period in several cases attributed to manufacturing issues. 4–6 Another cause of silicone IOL discoloration includes the pro- longed use of several medications. Progressive brown discoloration of silicone lenses occurred bilaterally in a patient on amiodarone. 7 Bilateral rose discoloration of silicone IOLs was documented in a woman taking rifabutin. 8 In the abovementioned study of experimental staining of silicone IOLs with methylene blue, bluish discoloration was detected within one hour of immersion. Similarly, we postulate that IOL staining in the case described likely occurred within several hours of implantation. Toxic anterior segment syn- drome (TASS) is an inflammatory process that characteristically occurs within 24 hours of cataract surgery. Diffuse corneal edema, as observed in the patient we describe, is a typi- cal sign of TASS. 9 Melles et al. evalu- ated the potential use of methylene blue as a stain for increasing visual- ization of the capsulorhexis during cataract surgery. While effective in staining the anterior capsule, its intraocular use was associated with an increased incidence of corneal of intraocular methylene blue dye during Figure 1. Left: Gross photograph of the explanted silicone lens (dry state), which is stained blue. A fragment of iris tissue as well as some fibers can be seen attached to the optic surface of the lens. Right: Light photomicrograph (sagittal cut) showing the blue discoloration of the internal substance of the lens optic. Source: Liliana Werner, MD, PhD