EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/422211
EW CATARACT 20 December 2014 Cataract/IOL complications: Moran CPC reports by Gregory D. Kramer, MD, Nick Mamalis, MD, and Liliana Werner, MD, PhD was placed in 0.5 ml of balanced salt solution and kept at 37 degrees C for 24 hours. The lens was subsequently reevaluated for color at 8-hour intervals. Gross and microscopic analysis demonstrated that the external sur- face of the IOL optic was homoge- neously stained blue. Evaluation of the sagittal section revealed that the internal substance of the lens optic was also stained blue, with darker staining noted toward the anterior and posterior optic surfaces (Figure 1). No change in color was noted during the 24 hours of immersion in balanced salt solution. Experimental staining of 4 silicone, 4 hydrophobic acrylic, 4 hydrophilic acrylic, and 4 polymeth- ylmethacrylate (PMMA) IOLs with methylene blue concentrations of 1%, 0.1%, 0.01%, and 0.001% were assessed at 6 and 24 hours after initial immersion. All lenses except those composed of PMMA were permanently stained blue. Staining was most intense in the hydrophilic acrylic lenses at all methylene blue concentrations. Comments To the best of our knowledge, the case that we describe is the first and only instance of intraoper- ative staining of a silicone IOL. 1 Whitish discoloration has been reported in several cases as early as 1 day after implantation secondary to the influx of water within the material and possible contamina- tion by exogenous molecules. 2,3 times per day and to continue the use of Zymar (gatifloxacin, Allergan) and Acular (ketorolac trometh- amine, Allergan) 4 times per day. A careful review of the details of the surgery revealed that the scrub nurse had mistakenly prepared methylene blue instead of trypan blue for anterior capsular staining. The patient missed several follow-up appointments and returned 1 month after surgery complaining of seeing a "red tint." BCVA was 20/150 with an IOP of 12 mm Hg. The cornea had 1+ striae and central moderate corneal edema. The entire IOL had a "blood red" color. Two months after surgery, the SI40NB was explanted and replaced with a +19.0 D AR40e lens (AMO). Upon explantation, the lens was evenly tinted blue. Six weeks after IOL exchange, an Nd:YAG capsulotomy was performed for dense posterior capsule opacifi- cation (PCO). On examination, the cornea was clear. BCVA gradually improved and was noted to be 20/30 at 5 months after surgery. Lab analysis and results Gross examination, light microsco- py, and photography of the explanted lens were performed in both the dry and hydrated states. In the dry state, 2 full-thickness sections were made through the IOL optic to obtain a cylindrical block from the center. Evaluation of the sagittal view by light micros- copy was conducted to analyze the distribution of blue staining. After evaluation in the dry state, the lens I t is critical to use the appropri- ate nontoxic dyes when stain- ing the anterior capsule during cataract surgery. Trypan blue is a dye used to enhance visual- ization during capsulorhexis. Given the multiple medical utilities of methylene blue dye, its widespread availability in the operating room, and the similarity in name and color to trypan blue, surgeons should be aware of this postoperative compli- cation and should take precautions to ensure that the correct dye is used during cataract surgery. The com- plication presented herein has been described in only one case report, to the best of our knowledge. Case report A 52-year-old man with a history of severe emphysema, alcoholism, and acid reflux initially presented with a chief complaint of decreased vision that gradually occurred over several years in the right eye (OD). 1 At that time, best corrected visual acuity (BCVA) was light perception OD and the patient could discern light projection in all four quadrants. Color perception was absent. In the left eye (OS), BCVA was 20/20. Slit lamp examination revealed a clear cornea and a hypermature white cataract without evidence of phaco- donesis OD. The view of the fundus was completely precluded secondary to the cataract, and the patient was referred for cataract surgery. Cataract surgery was performed almost 6 months later. During the capsulorhexis, the surgeon requested that the nursing staff prepare the blue dye to increase visualization. Phacoemulsification was performed uneventfully and a +19.0 D SI40NB IOL (Abbott Medical Optics, AMO, Abbott Park, Ill.) was implanted into the capsular bag. On postoperative day 1, BCVA was counting fingers OD. The IOP was 14 mm Hg. There was diffuse corneal edema, and the examiner was unable to determine the pres- ence or extent of cells or flare. The patient was instructed to increase the use of Pred Forte (prednisolone, Allergan, Irvine, Calif.) to 6 to 8 A case of TASS following inadvertent use cataract surgery Gregory D. Kramer, MD The widespread availability of methylene blue in the operating room and the similarity in name and color to trypan blue may lead to confusion. … Due diligence is necessary to ensure that the correct dye is used during cataract surgery. Nick Mamalis, MD Liliana Werner, MD, PhD