Trypan blue in macular pucker surgery: an evaluation of histology and functional outcome

To evaluate possible adverse effects of trypan blue on the ultrastructure of the human retina, to report on functional outcome of macular pucker surgery with and without the use of trypan blue, and to evaluate the ultrastructure of tissue harvested during surgery.

Experimental study and prospective matched-pair analysis of two consecutive, interventional case series.

Possible adverse effects on the ultrastructure of the human retina by trypan blue were evaluated in three donor eyes in an experimental study using trypan blue in concentrations of 0.02%, 0.15%, and 0.25%. The retinas were histologically evaluated. In the clinical study, the functional outcome (visual acuity, Goldmann perimetry) of 10 eyes of 10 consecutive patients with intraoperative use of trypan blue (0.15%) was analyzed (group 1) and compared with the functional outcome in a matched group of patients (preoperative visual acuity, pre- and postoperative lens status) who had undergone vitrectomy without trypan blue assistance (group 2). Only patients with an idiopathic macular pucker were included. Epiretinal tissue of all eyes was harvested and prepared for ultrastructural analysis using light and electron microscopy.

In the postmortem study, no significant alterations of the inner retina suggesting adverse effects of trypan blue concentrations of 0.02% were observed. In contrast, a disorganization of the innermost retina and an absence of the internal limiting membrane (ILM) was seen after the application of undiluted 0.15% and 0.25% trypan blue. In the clinical study, the median best-corrected visual acuity was 20/50 in both groups (range, 20/200-20/40) before surgery. Mean age was 70 years in group 1 (with trypan blue) and 69 years in group 2 (without trypan blue). Mean follow-up time was 4 months in group 1 and 5.6 months in group 2. Postoperatively, median visual acuity had increased to 20/32 (range, 20/100-20/25; Wilcoxon test P = 0.01) in group 1 and to 20/40 (range, 20/100-20/25; P = 0.09) in group 2. The difference between the two groups was not statistically significant (P = 0.4). Four of 10 patients without and 7 of 10 patients with trypan blue staining experienced an improvement of visual acuity (gain of 2 lines or more). No postoperative visual field defects were noted in either group. Histologic analysis of tissue harvested intraoperatively revealed the regular picture of undisturbed fibrocellular membranes. In some specimens, a layer of interspersed collagen was noted between epiretinal cells and the ILM, suggesting two different morphologic types of macular pucker. In a few sections, areas of cellular elements were detected adjacent to the retinal surface of the ILM.

Trypan blue in a concentration of 0.02% is not associated with morphologic alterations of the inner retinal layers in our postmortem study. After application of 0.15% and 0.25% trypan blue solutions, a disorganization of the inner retinal layers was observed; the ILM was absent. We did not find any adverse effects of an intraocular trypan blue concentration of 0.02% on functional status. Our study further indicates that the functional results of surgery with and without the use of trypan blue are comparable. As the question of toxicity of a dye can not be answered by morphological observations alone, further experimental studies will be needed.