Unexpected Incident During Cataract Surgery

To report a case of inadvertent vitreous staining with Trypan Blue during phacoemulsification and intraocular lens (IOL) implantation surgery.

Trypan Blue is the most frequently used dye agent in cataract surgery. It is used to stain the anterior capsule of the lens, facilitating its visualization and manipulation during cataract surgery. Trypan Blue staining of the anterior vitreous is uncommon, more frequent being linked to different pathologies associated - for example in eyes with pseudoexfoliation, ocular trauma or ocular surgery history.

The patient is a 59-year-old male who presented with the chief complaint of decreased vision in the left eye (LE), accentuated during the last 3 months. From the ocular history we note herpetic keratitis in his LE in 1987 and intraocular hypertension under topical treatment. The visual acuity was 0.05 in the LE and the slit lamp examination revealed central corneal opacity and dense posterior subcapsular lens opacification. The B-scan examination showed clear vitreous and flat retina.

During cataract surgery, the anterior capsule was stained with trypan blue under air bubble, irrigated and the anterior chamber was then filled with dispersive viscoelastic substance. We observed that the dye entered the vitreous cavity and the red fundus reflex disappeared. The following steps of the surgery were completed without any complications and the IOL was inserted into the capsular bag. The trypan blue staining of the vitreous persisted for 4 days after surgery and the patient’s best corrected visual acuity improved to 0.4. After the surgery we were able to perform visual field and optical coherence tomography examinations which revealed no pathological changes, thus we decided to stop the topical treatment. During the follow-up visits the IOP maintained in the normal range.

Taking into consideration that during the cataract surgery of his father we encountered a similar incident, we might consider this the particularity of the case.

The patient presented had no evidence of zonular weakness or any other known risk factors that are reported to be linked to the migration of dye to the posterior chamber and vitreous cavity. Trypan blue in the posterior segment increased the total duration of the surgical time and the risk of surgical complications due to the absence of the red fundus reflex. The dye disappeared in the first postoperative days, without causing any problems during the follow-up period.