CAPSULORHEXIS ASSISTED WITH TRYPAN BLUE IN MATURE
WHITE CATARACTS
Shereef Abd El Wahab,MD
Aim:To evaluate the efficacy of trypan blue for enhancing visualization of the capsulorehxis procedure during
phacoemulsification of mature white cataracts.
Subjects and methods: 11 eyes of 11 patients with mature white cataract underwent trypan blue assisted
phacoemulsification with intraocular lens (IOL) implantation. The patients were followed at the first day, first
week and first month postoperatively. Completion of capsulorhexis, phacoemulsification with IOL implantation
and postoperative best corrected visual acuity were measured.
Results: The dye improved the visualization of the anterior capsule and a complete capsulorhexis was
performed successfully in all eyes. All eyes had uneventful phacoemulsification with IOL implantation and all
eyes showed a postoperative visual acuity of > 6/24.
Conclusion : Trypan Blue assisted phacoemulsification in cases with mature white cataracts improves
visualization during capsulorhexis and assists in providing an excellent visual outcome in these patients.
Introduction:
Trypan blue is used to stain the capsule for better visibility during capsulorhexis in white cataracts. (I, 2)
Trypan blue 0.1 % has been used clinically to examine endothelial cell damage after cataract extraction
without adverse effects during 8 years of follow up (3). Trypan blue 0.1 % has not been found to be harmful to
the endothelium in a clinical study in which endothelial counts and morphology were evaluated both
preoperatively and postoperatively (1). It is unlikely to have a toxic effect on the endothelium or other
intraocular structures especially since it is washed out immediately. Besides white cataract, capsular staining
is helpful where the red reflex is poor or visualisation of the capsule is compromised. These may include
situations such as asteroid hyalosis, corneal scarring, corneal oedema, or a dark brunescent nucleus. In this
study 11 eyes with mature white cataract were operated upon and the capsulorhexis procedure was assisted
with trypan blue staining of the anterior capsule. The stain enhanced the visualization of the capsule in all
cases and made the rhexis procedure easier. The final visual outcome was excellent in all cases and we had
no cases of postoperative corneal haze or decompensation. And all cases had an IOL well placed in the
capsular bag.
Subjects and methods: Eleven eyes of 11 patients with mature white cataract were recruited prospectively
in this study. Inclusion criteria consisted of the presence mature white cataract with an absent red reflex. A
decision to perform dye assisted capsulorhexis and subsequent phacoemulsification surgery was taken in
cases where ,the surgeon felt that even with the brightest illumination of the microscope, the anterior capsule
is not sufficiently visible to facilitate a capsulorhexis without the dye. These patients had not been subjected to
any previous ocular surgical procedures. Patients with glaucoma , iritis , pseudoexfoliation were excluded
from the study.
A complete history was taken in all patients and all eyes had good vision before the onset of cataract. A
thorough ocular examination under a slit lamp microscope was performed in all eyes. A posterior segment
evaluation was done on ultrasonggraphy to rule out any posterior segment pathology as the fundus
examination was not possible because of the opaque lens.The preoperative factors evaluated were, the type
of cataract, and the preoperative best corrected visual acuity.All surgeries were performed under retro bulbar
lidocaine (Xylocaine 2%, Astra) and bupivacaine (Marcaine 0.5%, Astra) (1: 1) anaesthesia. A side port was
made and a clear corneal tunnel was fashioned at the 12 o'clock meridian. Sterile air was injected into the
anterior chamber through the side port incision. A volume of 0.1 ml of 0.1 % trypan blue (HEXIS BLUE, C.L.R.
MEDICALS INT’L INC., USA) was injected under the air bubble over the anterior capsule with a 27 gauge
cannula (fig 1). The anterior chamber was deepened with air to allow even contact of the dye with the lens
capsule and then washed with balanced salt solution after waiting for 10 seconds. A viscoelastic (Healon ;
Pharmacia Upjohn, USA) was injected into the anterior chamber. Capsulorhexis was initiated with a bent 26
gauge needle(fig 2) and a capsulorhexis forceps was used for completing a continuous curvilinear
capsulorhexis (fig 3). Following hydro procedures, phacoemulsification was accomplished by a "stop and
chop" manoeuvre using a Venturi based machine . Automated irrigation and aspiration was done and a
foldable three piece acrylic lens (Acrysof) was implanted using a holder and folder. Viscoelastic was then
aspirated using an automated irrigation and aspiration. Stromal hydration of the side port was done and the
wound was left unsutured. Subconjunctival gentamicin 20 mg and dexamethasone 1 mg was injected.
Fig1 Injection of Trypan blue
F
Fig 2 Initialization of rhexis
Fig 3 Rhexis completed
MAIN OUTCOME PARAMETERS
The parameters assessed during the surgery included the completion of capsulorhexis, phacoemulsification
and foldable intraocular lens implantation and the presence of complications, if any. Furthermore, any increase
in corneal haze intraoperatively was also noted. Patients were followed up postoperatively on day 1, week 1,
and month 1. Postoperative assessment included the record of the corneal clarity, position of the intraocular
lens, and best corrected visual acuity and complications, if any.
RESULTS
The mean age of the patients was 64.32 (SD 14.36) years (range 60-76 years). There were six males and five
females. All patients had a preoperative visual acuity of <6/60. The main incision and the side port were
stained in all eyes. The anterior capsule was stained in all eyes sufficiently so that the capsulorhexis was
successfully completed without any complication in all eyes .No extension of the capsulorhexis occurred in any
of the cases. Hydro procedures were done in all eyes . Phacoemulsification of the nucleus with stop and chop
technique and aspiration of the cortical material was uneventful. The capsulorhexis margin was visualized
throughout the procedure and the stained peripheral anterior capsular rim aided in the emulsification of the
fragments with the chopper. Foldable lenses were implanted in the bag in all cases. On the postoperative day
1, there was no residual staining of the anterior capsule and all eyes showed a quiet anterior chamber with
normal intraocular pressure. The best corrected visual acuity at the last follow up was 6/6 in eight eyes and
between 6/24 and 6/9 in the other 3 cases.
DISCUSSION
Continuous curvilinear capsulorhexis (CCC) described by Gimbel and Neuhann (4) revolutionized cataract
surgery by creating an opening in the anterior capsule of the crystalline lens that is resistant to tears during
phacoemulsification and IOL implantation. However CCC is often difficult in eyes with advanced cataract
because of lack of red reflex. Inadequate CCC increases the risk of radial tears towards or beyond the lens
equator risking the safety of the phacoemulsification procedure. Phacoemulsification is the preferred technique
of cataract surgery at present (5) and it allows early visual rehabilitation. However, a successful
phacoemulsification necessitates a good capsulorhexis which may be difficult in cases of mature cataracts and
absence of red reflex because of suboptimal visualisation of the anterior capsule. Many methods have been
used to enhance the visualization of the anterior capsule during CCC in eyes with advanced cataract including
side illumination with an endoilluminator (6), hemocoloration with autologous blood(7),and the use of a high
frequency diathermy probe (8). As mentioned above, vital steps such as capsulorhexis, nuclear emulsification,
residual cortex removal, and foldable intraocular lens implantation are dependent upon the ability to visualize
the capsular bag anatomy. Capsular staining has been used previously in various studies in mature white
cataracts (1,6) and for learning the initial steps of phacoemulsification during training (9,10). Trypan blue 0.1 %
facilitated the delineation of the lenticular morphology in all eyes (5). It helped in performing the rhexis and its
visualisation during phacoemulsification in cases of mature cataracts (1).Other dyes such as Fluorescein
sodium (11) Indocyanine green (1) have been used in staining the anterior capsule in advanced cataracts.
Indocyanine green is however more expensive than trypan blue and there are no reports mentioning its
superiority to trypan blue. In this study the visualization of the anterior capsule was enhanced in all cases
stained with trypan blue, there were no complications neither intraoperatively nor postoperatively, and by the
end of the follow up period all patients had a satisfactory visual outcome. These results are similar to those of
Melles (1) who found the trypan blue dye to be an excellent tool in enhancing visualization of the anterior
capsule in advanced cataract.
In conclusion trypan blue is a useful tool that helps in visualizing the anterior capsule during the rhexis
procedure in mature cataracts, it is used in a 0.1 % concentration without any complications and is available in
the market for a relatively reasonable cost that is worth paying to avoid jeopardizing the visual outcome of the
surgical procedure when performing phacoemulsification in mature cataracts.
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