Methods

This observational case series includes eyes of 5 patients who underwent otherwise uncomplicated phacoemulsification surgery ( Table ) at a single academic institution. The Johns Hopkins Hospital Institutional Review Board approved this retrospective review of patient data, and the study was HIPAA compliant. Although 1 of the 5 patients reported a possible history of trauma to both eyes in childhood, no eyes had any evidence of zonular pathology noted on preoperative examination or at any time during surgery. One of the 5 eyes had a history of uveitis and underwent synechialysis prior to cataract extraction. In all 5 cases, iris retractors were used to enlarge the pupil or to stabilize a floppy iris.

Trypan blue capsule staining was performed after placement of iris retractors, and the same staining technique was used in all 5 cases. Trypan blue was injected into the anterior chamber under an air bubble and then irrigated with balanced salt solution, followed by a dispersive viscoelastic ( Figure 1 , Top left). The trypan blue was noted to flow under the iris, and in some cases, reflux of trypan was observed prior to hydrodissection ( Figure 1 , Top center, Top right).

Images of posterior capsule staining with trypan blue during cataract surgery. (Top left) Trypan blue is injected under an air bubble and moves under the iris, which is elevated by retractors. (Top center) Trypan travels posteriorly and stains the posterior capsule, which is seen here as a light blue hue against an otherwise red reflex (arrow). (Top right) An air bubble refluxes back into the anterior chamber during hydrodissection and is followed by a small amount of trypan blue, which had been sequestered posteriorly. (Bottom) Nuclear and cortical removal (Bottom left and Bottom center, respectively) are made difficult by posterior capsule staining and consequent loss of red reflex. The intraocular lens is positioned in the blue-stained capsular bag (Bottom right).

Results

In all 5 cases, the posterior capsule was noted to be stained with trypan blue during nuclear and cortical removal, causing loss of the red reflex and consequent difficulty visualizing the posterior capsule for the remainder of the surgery ( Figure 1 , Bottom left, Bottom center). Despite the poor visualization, none of the eyes had posterior capsular rupture or any other intraoperative complication, and the intended lens implant was successfully placed in the capsular bag ( Figure 1 , Bottom right). The posterior capsule staining persisted on postoperative day 1 but resolved by postoperative day 8 in all cases, with no long-term complications.

Cataract surgery was also performed in the fellow eye in all 5 patients, and none of these surgeries resulted in posterior capsule staining with trypan blue ( Table ). Trypan blue was used in 3 of the 5 fellow-eye cases, 1 of which did not involve the concomitant use of iris retractors. In 1 case involving both trypan blue and retractors, the trypan blue was placed under a dispersive viscoelastic (Patient 4). In the final case (Patient 5), the pupil was sufficiently dilated to use trypan blue before placement of iris retractors to stabilize the floppy iris.

On review of operative records for the 3-year period during which these 5 cases occurred, a total of 491 cataract surgeries were performed, 71 of them involving trypan blue, and 22 of them involving both trypan blue and iris retractors. We therefore observed posterior capsule staining in 7% of all cases involving trypan blue (5/71) and in 23% of cases involving both trypan blue and iris retractors (5/22).