Inadvertent Corneal Tattooing- Accidental Injection Of Trypan Blue Into Corneal Stroma While Staining Anterior Lensure Capsule

We report the natural course of the accidental injection of trypan blue into the corneal stroma while performing a routine cataract surgery by a resident during a training session. The corneal staining resolved with conservative medical treatment over 2 weeks. This case describes the anterior segment optical coherence tomography (ASOCT) features of corneal staining. It emphasizes on the relatively benign nature of this dye and the follow-up course. This complication can be avoided by using sharp-tipped instruments, proper wound construction, and proper depth perception, which can be done by adjusting the microscope. 

It was conducted in a tertiary hospital with residential surgical training centre . Trypan blue dye has been used in various intraocular surgeries and its safety profile has been well documented. Anterior segment optical coherence tomography (ASOCT) is an efficient tool providing layer-by-layer analysis of corneal pathology.We report a case of inadvertent injection of trypan blue into the cornea by a trainee while attempting to stain the anterior capsule during routine cataract surgery .

A 70-year-old female came with complaints of gradual dimness of vision for distance in her left eye since 2 years. Her best-corrected vision (BCVA) was 20/20 in her right eye and 20/200 in her left eye. Clinical examination revealed pseudophakia in the right eye and nuclear cataract with posterior subcapsular cataract in the left eye. Patient was advised to undergo left eye cataract surgery with posterior chamber intraocular lens (PCIOL) implantation.

During surgery, there was premature entry into cornea by trainee and instead of injecting the trypan blue (0.06%)  dye into the anterior chamber, there was accidental injection of dye into the corneal stroma, resulting in diffuse staining of the cornea . As the visualization of anterior segment worsened, further placement of IOL was deferred. In the immediate postoperative period, slit-lamp examination revealed diffuse stromal edema and corneal blue staining. She underwent  slit-lamp photography and ASOCT for documentation .

Patient was advised to use tapering dose of topical dexamethasone and hypersol 4% eye drops 4 times for 2 weeks. During her follow-up visit, in the next 2 weeks, the corneal edema completely resolved . The findings were comparable to the ASOCT . The patient underwent uneventful secondary IOL placement with residual cortex wash after 2 weeks with PCIOL implantation resulting in a good surgical outcome with postoperative uncorrected distance vision of 20/20.

To conclude, our case thus emphasizes that although the use of trypan blue appears to be free of undesirable effects, the surgeon should be prepared for such temporary adverse events while using trypan blue during cataract surgery. This staining can lead to both stromal edema and DMD which can be documented by AS-OCT.

This complication can be avoided by using sharp-tipped instruments, proper wound construction, proper depth perception, directing the needle or cannula toward the center of the lens during insertion, and ensuring complete insertion of the needle tip inside anterior chamber (AC) before injection.