We thank Dr Coroneo for the comments and interest in our article. We agree that if the posterior capsule is stained with trypan blue, completion of the surgery, although more difficult, can still be performed successfully, and we believe it is important to emphasize this.
We prefer to delay instillation of trypan blue and viscoelastic until after iris retractors are placed. As described in our article, trypan blue is instilled under an air bubble. Instillation of trypan blue before retractor placement can make visualization of the peripheral iris more difficult, making retractor placement harder, and may result in suboptimal staining of the peripheral anterior capsule. In addition, viscoelastic can flatten the iris, making capture of the iris by retractors more difficult. In 4 of our reported cases, paracenteses were made with a 15-degree blade directed parallel to the iris to avoid perforating the peripheral iris, and in 1 case, 25-gauge needles were used similarly. We believe that directing the paracentesis, whether with a blade or with a needle, perpendicular to the cornea risks damage to the peripheral iris. Balanced salt solution was injected as needed to avoid hypotony and to maintain a deep anterior chamber while placing the paracenteses.
We emphasize that avoiding elevating the peripheral iris with iris retractors, and not raising the intraocular pressure while trypan blue is in the anterior chamber, should minimize the risk of posterior capsule staining.