Diffuse retinal pigment epithelium atrophy following pars plana vitrectomy for high myopic macular hole assisted by Brilliant Blue G: A case report



To describe a case of diffuse retinal pigment epithelium (RPE) disturbance following 23-gauge pars plana vitrectomy (PPV) with the inverted internal limiting membrane (ILM) technique and Brilliant Blue staining for a high myopic macular hole (MH).


A 53-year-old pseudophakic high myopic female was referred to the Vitreoretinal Department with a diagnosis of a full thickness myopic MH of her right eye. Her initial visual acuity was 20/40 of her right eye and 20/20 in the left eye. She underwent routine PPV with inverted ILM flap assisted by repeated brilliant blue staining. Surgery was uneventful without any intraoperative complications. MH closure was obtained within the first days. Three weeks postoperatively, the patient reported a decline in visual acuity of her right eye. Upon examination, her visual acuity decreased to 20/400. Fundus examination showed diffuse pigmentary changes with mottling at the level of the RPE, which later progressed to severe diffuse atrophy, as confirmed by fundus autofluorescence (FAF). After 12 months, visual acuity remained 20/400 with widespread areas of atrophy.


Uncomplicated routinary PPV assisted with Brilliant Blue, can lead to unexplained atrophy of the RPE. Possible causes include light phototoxicity, dye toxicity or both.


Indocyanine Green and Brilliant Blue G (BBG) have been used routinely for ILM dying. Both have high affinity to basal membranes such as the ILM, although concerns about retinal toxicity, as well as a better safety profile for BBG, has shifted the use to the latter. We present a case of severe RPE disturbance after an uneventful vitrectomy for myopic MH.

Case report

A 53-year-old pseudophakic high myopic female was referred to the vitreoretinal department of our clinic with a 4-month history of central scotoma. She had had a radial keratotomy at age eighteen, with a preoperative refraction of −15.00 diopters in both eyes. On examination, the patient presented a best corrected visual acuity (BCVA) of 20/40 on the right eye and 20/20 on her left eye. Optical coherence tomography (OCT) showed a full thickness macular hole (FTMH) ( Fig. 1 a) in the right eye. The patient underwent routine three-port pars plana vitrectomy (PPV) (EVA system; DORC Netherlands) with Brilliant Blue G (Brilliant Blue®, 0,025%; DORC Netherlands) with core vitrectomy followed by posterior hyaloid removal, staining of the ILM with BBG, ILM peel and positioning of an inverted ILM flap over the macular hole. A focal light fiber endoilluminator was used for the procedure. An area of ILM of approximately two-disc diameters was peeled surrounding the macular hole. Staining was repeated twice to ensure a complete ILM removal, as we perform routinely. Duration of each staining was 6–10 seconds. Fluid-air exchange was performed, and sulfur hexafluoride (SF 6 ) 20% was used as endotamponade. Strict face-down positioning was advised for five days.

Fig. 1

OCT images: (A) Preoperative aspect of the MH. Reduced choroidal thickness is observed, with continuous RPE line and normal outer retinal layers. (B) OCT taken at day 1 after surgery showing inner hyperreflective line corresponding to the gas bubble interface. (C) At three-weeks post-op, the presence of hyperreflective subretinal material is observed, corresponding to areas of RPE thickening and migration. (D) Severe disruption of external retinal layers and decrease in retinal thickness. A decrease of the subretinal material and irregular RPE are observed.

MH closure was achieved within the first week ( Fig. 1 b). At the three-week follow-up visit, the patient complained of a central scotoma and her visual acuity had dropped to 20/400. Mild RPE changes were noted initially on examination ( Fig. 2 a). OCT showed severe disruption of the external retinal layers, as well as extensive areas of RPE migration and thickening ( Fig. 1 c and d). Fundus autofluorescence (FAF) showed diffuse areas of both hypo- and hyperautofluorescence involving the macular and peripapillary areas and extending to the upper mid-periphery ( Fig. 3 a). Progression and coalescence of the distinct areas of RPE atrophy was observed on consecutive follow-up visits ( Fig. 3 b and c). There was no history of unusual exposure to sunlight or UVA/UVB radiation sources, and she was not taking any systemic medications at the time.

Jan 3, 2022 | Posted by in OPHTHALMOLOGY | Comments Off on Diffuse retinal pigment epithelium atrophy following pars plana vitrectomy for high myopic macular hole assisted by Brilliant Blue G: A case report
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