Anterior and posterior capsulorhexis in pediatric cataract surgery with or without trypan blue dye

Anterior and posterior capsulorhexis in pediatric cataract surgery with or without trypan blue dye
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   Anterior and posterior capsulorhexis in pediatriccataract surgery with or without trypan blue dye Randomized prospective clinical study   Jagjit S. Saini, MD, Arun K. Jain, MD, Jaspreet Sukhija, MS, Poonam Gupta, MS,Vandana Saroha, MS  Purpose:  To evaluate the clinical efficacy of trypan blue 0.1% dye (Blurhex   ) increating a complete anterior and posterior capsulorhexis during pediatric cataractsurgery. Setting:  Tertiary eyecare center, Postgraduate Institute of Medical Education andResearch, Chandigarh, India.  Methods:  In a prospective randomized study, an anterior (ACCC) and posterior(PCCC) continuous curvilinear capsulorhexis were performed in pediatric patients.In Group 1 (n  19), the ACCC and PCCC were created without use of trypanblue dye. In Group 2 (n  23), intracameral trypan blue dye was used to stain theanterior and posterior capsules.  Results:  In Group 1, 14 eyes (73.6%) had a complete ACCC and 10 (52.6%) hada complete PCCC. In Group 2, 21 eyes (91.3%) had a complete ACCC and 19(82.6%) had a complete PCCC. Conclusion:  In cases of pediatric cataract, staining the anterior and posteriorcapsules with trypan blue 0.1% allowed recognition of capsule flaps and facili-tated the creation of complete ACCCs and PCCCs.  J Cataract Refract Surg 2003; 29:1733–1737 © 2003 ASCRS and ESCRS O ptimal management of pediatric cataract requiresa surgical procedure that provides a long-termclearvisualaxis,safeintraocularlens(IOL)implantationin the capsular bag, and aggressive management of am-blyopia, if present. Many surgical techniques to managepediatric cataract have been advocated, with most being only of historical importance. Procedures such as discis-sion, linear extraction, and intracapsular extraction areassociated with significant intraoperative and postoper-ative complications. 1  At present, extracapsular cataractextraction (ECCE) or phacoaspiration combined withprimary posterior capsulotomy, anterior vitrectomy,and IOL implantation in the capsular bag is usually theprocedure of choice in older children and is mandatory in younger children. 2 The incidence of postoperative posterior capsuleopacification(PCO)ishighinpediatriccases.Aprimary posterior capsulorhexis—a posterior continuous curvi-linear capsulorhexis (PCCC)—combined with opticcapture of the IOL, 3,4 anterior vitrectomy, 5 or both de-creases the frequency of PCO, retains a clear visual axis,and prevents amblyopia. Performing PCCC in childrencan be difficult, however, because of the thin, transpar-ent, and elastic nature of the anterior capsule. 6 Creating a complete anterior continuous curvilinear capsulo-  Accepted for publication February 7, 2003.From the Department of Ophthalmology, Post Graduate Institute of   Medical Education and Research, Chandigarh, India.Noneoftheauthorshasafinancialorproprietaryinterestinanymaterial or method mentioned.Reprint requests to Jagjit S. Saini, MD, Professor, Department of Oph-thalmology,PostGraduateInstituteofMedicalEducationandResearch,Chandigarh 160012, India. E-mail: © 2003 ASCRS and ESCRS 0886-3350/03/$–see front matterPublished by Elsevier Inc. doi:10.1016/S0886-3350(03)00229-3  rhexis (ACCC) is also challenging in pediatric patients.Because of the elasticity and tension of the anterior cap-sule, the risk for radial extension of the tear is high. 7 This study evaluated the success of capsulorhexis inpediatriccaseswithandwithouttheuseofcapsulestain-ing with trypan blue 0.1% dye in performing ACCCand PCCC during cataract extraction. To our knowl-edge,therearenopublishedclinicalstudiesontheuseof trypan blue dye in cases of pediatric cataract. Patients and Methods The 42 patients in this study had congenital, develop-mental (unilateral or bilateral), or traumatic cataract. Themean age of the 35 boys and 7 girls was 4.13 years (range 3 to15 years), with most patients younger than 5 years (Table 1).There was no red reflex in eyes with traumatic cataract and a faint red reflex in eyes with developmental and congenitalcataract.Based on the day of the week they had surgery, the pa-tientswererandomlyassignedtohavesurgerywithorwithoutthe use of intraoperative trypan blue. In Group 1 (19 eyes),cataractextractionwasdonewithoutstainingthecapsulewithtrypan blue. In Group 2 (23 eyes), the capsule was stained with trypan blue 0.1% (Blurhex   ) during the creation of the ACCC and PCCC. The number of eyes in both groups witha complete ACCC and PCCC, surgical difficulties, and com-plications was recorded. In all cases, ECCE or phacoaspira-tion, PCCC, anterior vitrectomy, and posterior IOL (PCIOL) implantation in the bag were attempted. The IOL(811C, Pharmacia and Upjohn) was of heparin-surface-mod-ified poly(methyl methacrylate) (PMMA).One surgeon (J.S.S.) performed all procedures. Beforethe dye was injected, the anterior chamber was filled with a sterile air bubble through a limbal side-port stab incision.Then, 0.1 to 0.2 mL of dye was injected into the anteriorchamber through a 27-gauge cannula. After 30 to 40 secondspassed, allowing the dye to stain the capsule, the excess dye was thoroughly removed with fortified balanced salt solution(BSS Plus  ). The anterior chamber was filled with sodiumhyaluronate1.4%(HealonGV   ),andanACCCwasinitiated with a 26-gauge cystotome and completed with a Utrata for-ceps (Figure 1). Hydrodissection was performed and a com-plete continuous curvilinear capsulorhexis (CCC) created inall eyes. After the cataractous lens material was removed, the pos-terior capsule was stained with trypan blue dye under an airbubble. The procedure used to stain the anterior capsule wasrepeated except magnification was increased to create a 2.5 to3.0 mm round PCCC (Figure 2). To facilitate manipulationintherestrictedarea,thecapsularbagwasfilledwithviscoelas-tic material. After the PCCC was complete, an anterior vit-rectomy was done and the IOL was implanted in the bag  without posterior optic capture. Results Table 2 shows the ACCC and PCCC findings inboth groups. In Group 1, in which no dye was used, the Table 1.  Age distribution by group. Group Age (Y) < 5 5–10  > 10 1 (no dye) 13 4 22 (dye) 18 4 1 Figure 1.  (Saini) Trypan-blue-stained edges of an ACCC.  Figure 2.  (Saini) The edge of PCCC is clearly delineated afterstaining with trypan blue. TRYPAN BLUE FOR PEDIATRIC CAPSULORHEXIS  J CATARACT REFRACT SURG — VOL 29, SEPTEMBER 2003 1734   ACCC was complete in 14 eyes (73.6%), all of whichhad IOL implantation in the bag. In 5 eyes, the ACCC was abandoned as the capsule tear extended radially; inthese cases, an anterior vitrectomy was performed, theIOL was placed in the sulcus, and a PCCC was notattempted. In 4 eyes (21.0%), the ACCC was completebut a complete PCCC could not be accomplished. Inthese cases, the PCCC was initiated as a slit opening  with a bent needle, followed by an attempt to completeaCCCwiththehelpofacapsule-holdingforceps.Whenthe capsulorhexis began extending linearly toward thelens equator, further pulling on the capsule was stoppedandavitrectomycutterwasusedtoenlargetheposteriorcapsule opening. In 3 of these cases, secondary surgery  was required because PCO developed. In the fourthcase, the visual axis was clear. The PCCC was completein 10 eyes (52.6%).In Group 2, in which trypan blue was used, 21 eyes(91.3%) had a complete ACCC. In 2 eyes (8.7%), the ACCC extended radially and was abandoned. In the eye with traumatic cataract, a D-shaped capsulorhexis wascreated, avoiding the capsule tear. Although the ACCC was not circular, the procedure was considered success-ful. The PCCC was complete in 19 eyes (82.6%). Ineyes with traumatic cataract, the contrast after anteriorcapsule staining was significantly greater than in eyes with a congenital or developmental cataract, in whichstaining was performed against a faint red reflex. In allcases,posteriorcapsulestainingwasfainterthananteriorcapsule staining. An IOL was implanted in all eyes; it was in the bag in 19 eyes and in the sulcus in 4 eyes.No secondary surgery was required in any Group 2 eye.The rate of successful of CCC (ACCC and PCCC) wascomparablebetweenGroups1and2inpatients5to10 years old and older than 10 years (Table 2). Signifi-cantly more eyes in Group 2 had a complete ACCC andPCCCthaninGroup1inpatientsyoungerthan5years.Use of the dye led to no intraoperative complica-tions.ItwashedoffeasilywithBSSPlusandstainedonly the capsule. Postoperatively, the anterior chamber reac-tion was similar between the 2 groups. Discussion In cases of pediatric cataract, performing cataractextraction with anterior vitrectomy and PCCC is essen-tial to retaining a clear visual axis. 2  A complete ACCCand PCCC facilitate IOL placement in the bag with or without posterior optic capture. 4 The ACCC andPCCC can be difficult to perform because of the elastic-ity and tension of the capsule in children. 7  Also, at-tempting PCCC in the presence of poor visibility andpositive vitreous pressure, as seen in pediatric patients,can further complicate the procedure and may cause aninadvertent radial tear. 6 In his study, Gimbel 4 identified poor posterior cap-sule visibility during surgery as the main difficulty inaccomplishing a complete PCCC in 37.5% of cases.Van Cauwenberge and coauthors 8 report 32 cases(4.9%) of complicated PCCC in a 1-year retrospectiveanalysis of 650 adult patients. The most frequent prob-lem was the inability to create a central capsulorhexis of the optimum size, which could not be accomplished in44% of cases. In 37% of eyes, creating a completePCCC was difficult because of poor visibility or an an-atomically changed capsule.Capsule-staining dyes have been used to improvevisibility and increase the rate of complete ACCCs andPCCCs. 9,10 The clinical safety of trypan blue, a vitalstain, was proved in 1970. 11 The dye has been usedclinically to examine endothelial cell damage after cata-ract extraction without adverse effects for as long as8yearspostoperatively. 12  Whenusedinaconcentrationof 0.1%, trypan blue is unlikely to be toxic to the endo-thelium or other intraocular structures. The chances of toxicity are less likely if the dye is washed out soon afterit is injected into the anterior chamber. 13 It is best to use the lowest effective concentration of the dye in children as trypan blue is potentially carcino-genic and the long-term side effects are not known. In1study, 14 aconcentrationaslowas0.0125%stainedthe Table 2.  Number and percentage of eyes with a complete ACCC and PCCC.  Age(Y)Number of Eyes (%)Group 1(No Dye, n  19)Group 2(Dye, n  23) ACCC PCCC ACCC PCCC  5 9/13 (69) 7/13 (54) 17/18 (94) 16/18 (89)5–10 3/4 (75) 2/4 (50) 3/4 (75) 2/4 (50)  10 2/2 (100) 1/2 (50) 1/1 (100) 1/1 (100) ACCC  anteriorcontinuouscurvilinearcapsulorhexis;PCCC  pos-terior continuous curvilinear capsulorhexis TRYPAN BLUE FOR PEDIATRIC CAPSULORHEXIS  J CATARACT REFRACT SURG — VOL 29, SEPTEMBER 2003  1735  capsule satisfactorily and concentration of 0.1% effec-tively stained the anterior capsule even under dispersiveviscoelastic material. Dye-induced neoplasms have beenreported when the dye was injected intravenously orintraperitonially at a much higher concentration and with more frequent application in experimentalmodels. 15 Dye-enhanced capsule visibility helps successfulcreation of an ACCC in eyes with hypermature andtraumatic cataract, in which it is difficult to locate a capsule tear on the background of a milky cortex ordense cataract. 13 Recently, Sharma and coauthors 16 re-port using the dye to remove posterior capsule plaque.In our series, we used a PMMA 811C lens. Perma-nent blue discoloration of hydrogel IOLs from the in-traoperative use of trypan blue dye has been reported. 17 In a digital image analysis of trypan blue and fluoresceinstaining of the anterior lens capsule and IOLs, uptake of trypan blue by the AcrySof    IOL (Alcon) was greaterthan by PMMA and silicone lenses, which did not stainor stained minimally. 18 Thus, AcrySof IOLs should notbe implanted during pediatric cataract surgery if trypanblue dye is used. In our study, none of the IOLs wasstained during the follow-up. We found that injecting a small amount of trypanblue to stain the capsule facilitates the 2 crucial steps inpediatriccataractsurgery  —  ACCCandPCCC.Staining ocular tissue using ophthalmic dyes enhances visual dif-ferentiation and makes manipulation of tissues easier.Dyes such as fluorescein sodium and indocyanine green(ICG) have a large margin of safety in humans. 19 Theability of fluorescein sodium, ICG, and trypan blue toenhance visualization of intraocular tissues during vari-ousstepsofmodernphacoemulsificationprocedureshasbeen studied extensively. 9,10,20 Dye delineates the cap-sule completely, and factors such as a poor red reflex donot impede the creation of the CCC. 10 Staining en-hances visualization of the posterior capsule flap, whichcan be easily seen against the transparent anterior hya-loid face of the vitreous. In addition, the edge of a mis-directedcapsuleflapcanbespottedduringCCCandtheCCCmodifiedaccordingly. 13 Insurgeryincomplicatedcases of traumatic cataract, capsule tears can be identi-fied, allowing the creation of a complete CCC whileavoiding the tear. 13  We successfully performed a D-shaped CCC in an eye with traumatic cataract toavoid a preexisting anterior capsule tear.Our results show that in patients younger than15 years, intraoperative capsule staining with trypanblue helps improve the rate of complete ACCC andPCCC. Creating a capsulorhexis without the dye wasmore difficult in children younger than 5 years than inthose 5 years and older. When no dye was used, the ACCC and PCCC in children younger than 5 years wascomplete in 69.2% and 53.8% of cases, respectively. Whentrypanbluewasused,theACCCwascompletein94.4% and the PCCC in 88.8% of children youngerthan5years,indicatingthesignificantbenefitofcapsulestaining in these eyes.In our study, 3 of 19 eyes in which trypan blue wasnot used required membranectomy as a secondary pro-cedure. No eye in which the dye was used required a second surgery. Thus, a complete ACCC and PCCC,in-the-bag IOL implantation, and anterior vitrectomy reducetheincidenceofsecondaryprocedures.Complete ACCC and PCCC also help ensure safe in-the-bag IOLimplantation. Based on these results, we recommend wider use of intraoperative capsule-staining dyes in pe-diatric cataract surgery. References 1. Chandler PA. Surgery of congenital cataract. Am J Oph-thalmol 1968; 615:663 – 6742. BenEzra D, Cohen E. Posterior capsulectomy in pediat-ric cataract surgery; the necessity of choice. Ophthalmol-ogy 1997; 104:2168 – 21743. Gimbel HV, DeBroff BM. Posterior capsulorhexis withoptic capture: maintaining a clear visual axis after pediatriccataract surgery. J Cataract Refract Surg 1994; 20:658 – 6644. Gimbel HV. Posterior capsulorhexis with optic capturein pediatric cataract and intraocular lens surgery. Oph-thalmology 1996; 103:1871 – 18755. Basti S, Ravishankar U, Gupta S. Results of a prospectiveevaluation of three methods of management of pediatriccataracts. Ophthalmology 1996; 103:713 – 7206. Vasavada A, Desai J. Primary posterior capsulorhexis with and without anterior vitrectomy in congenital cata-racts. J Cataract Refract Surg 1997; 23:645 – 6517. Auffarth GU, Wesendahl TA, Newland TJ, Apple DJ.Kapsulorhexistechnik bei Kindlicher Katarakt; Dar-gestellt am Kakinchenmodell. Ophthalmologe 1994; 91:518 – 5208. VanCauwenbergeF,RakicJ-M,GalandA.Complicatedposterior capsulorhexis: aetiology, management and out-come. Br J Ophthalmol 1997; 81:195 – 1989. Pandey SK, Werner L, Escobar-Gomez M, et al. Dye-enhancedcataractsurgery.Part3:posteriorcapsulestain- TRYPAN BLUE FOR PEDIATRIC CAPSULORHEXIS  J CATARACT REFRACT SURG — VOL 29, SEPTEMBER 2003 1736  ing to learn posterior continuous curvilinear capsulorhexis. J Cataract Refract Surg 2000; 26:1066 – 107110. Pandey SK, Werner L, Escobar-Gomez M, et al. Dye-enhanced cataract surgery. Part 1: anterior capsule staining for capsulorhexis in advanced/white cataract. J CataractRefract Surg 2000; 26:1052 – 105911. Stocker FW, King EH, Lucas DO, Georgiade NA. Clin-ical test for evaluating donor corneas. Arch Ophthalmol1970; 84:2 – 712. Norn MS. Per operative trypan blue vital staining of cor-neal endothelium; eight years ’  follow up. Acta Ophthal-mol 1980; 58:550 – 55513. Kothari K, Jain SS, Shah NJ. Anterior capsular staining  with trypan blue for capsulorhexis in mature and hyper-mature cataracts; a preliminary study. Indian J Ophthal-mol 2001; 49:177 – 18014. Yetik H, Devranoglu K, Ozkan S. Determining the low-est trypan blue concentration that satisfactorily stains theanterior capsule. J Cataract Refract Surg 2002; 28:988 – 99115. Melles GRJ, de Waard PWT, Paymeyer JH, Beekhuis WH. Trypan blue capsule staining to visualize the capsu-lorhexisincataractsurgery.JCataractRefractSurg1999;25:7 – 916. Sharma N, Gupta V, Vajpayee RB. Trypan-blue-assistedposterior capsule plaque removal [letter]. J Cataract Re-fract Surg 2002; 28:916 – 91717. Werner L, Apple DJ, Crema AS, et al. Permanent bluediscoloration of hydrogel intraocular lens by intraopera-tivetrypanblue.JCataractRefractSurg2002;28:1278 – 128618. Fritz WL. Digital image analysis of trypan blue and flu-orescein staining of anterior lens capsules and intraocularlenses. J Cataract Refract Surg 2002; 28:1034 – 103819. Hogan RN, Zimmerman CF. Sodium fluorescein andother tissue dyes. In: Zimmerman TJ, ed, Textbook of Ocular Pharmacology. Philadelphia, PA, Lippincott-Raven, 1997; 849 – 86320. Werner L, Pandey SK, Escobar-Gomez M, et al. Dye-enhanced cataract surgery. Part 2: learning critical stepsof phacoemulsification. J Cataract Refract Surg 2000;26:1060 – 1065 TRYPAN BLUE FOR PEDIATRIC CAPSULORHEXIS  J CATARACT REFRACT SURG — VOL 29, SEPTEMBER 2003  1737
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