Vital Dyes For Chromovitrectomy: Colours for the Vitreoretinal Surgeon!!!

Size: px

Start display at page:

Download "Vital Dyes For Chromovitrectomy: Colours for the Vitreoretinal Surgeon!!!"

Lester Hampton
6 years ago
Views:

1 174 Kerala Journal of Ophthalmology Vol. XX, No. 2 O C U L A R PHARMACOLOGY Vital Dyes For Chromovitrectomy: Colours for the Vitreoretinal Surgeon!!! Dr. Meena Chakrabarti MS DO DNB, Dr. Valsa Stephen MS DO DNB, Dr. Sonia Rani John DNB, Dr. Arup Chakrabarti MS DO Chromovitrectomy 1 refers to the application of vital dyes during retinal surgery to visualize preretinal tissues and membranes. Chromovitrectomy arises from the difficulty in visualizing and removing the several thin and transparent tissues in the vitreoretinal interface including the internal limiting membrane (ILM), epiretinal membrane (ERM) and the vitreous. These tissues are involved in the pathogenesis of several macular disorders including macular holes and diabetic macular oedema. Surgical manipulation of these poorly visualized tissues have been shown to induce gliosis, iatrogenic chorioretinopathy and phototoxicity. Staining of these tissues with vital dyes may improve their visibility, enhance the ability to peel them as well as ensure complete removal of all tissues, which may lead to a better visual result postoperatively with a lesser recurrence rate. An ideal vital dye for chromovitrectomy should have the ability to selectively stain the internal limiting membrane and the epiretinal membrane, leaving the retina unstained. It should provide adequate colour difference between the stained ILM/ERM and the normal retina. Other favorable characteristics are 1) rapid elimination from vitreous cavity 2) photochemical stability 3) solubility in balanced salt solution 4) absence of toxicity and 5) an adequate light absorption profile. The vitreoretinal interface staining agents have been used since They can be classified into three generations depending on the time of introduction. Chakrabarti Eye Care Centre, Kochulloor, Trivandrum tvm_meenarup@sancharnet.in First Generation: (2000): Indocyanine Green 2 (ICG) Second Generation:(2003): Infracyanine Green 3 (IFCG), Trypan Blue 4 (TB) and Triamcinolone accetonide 9 (TA) Third Generation (2005): Brilliant Blue G 5 (BBG), Chicago Blue 7, Bromophenol blue 7, Patent blue 8 (PB). Table 1 gives the comparison of staining characteristics and structures of various dyes used for chromo vitrectomy. Indocyanine Green (ICG) ICG is a tricarbocyanine anionic dye with a molecular formula of C 43 H 47 N 2 NaO 6 S 2 and a molecular weight of 775 Daltons. This green dye has amphiphilic properties and hence interacts biochemically with different human tissues. ICG demonstrates greatest affinity to the extracellular matrix components 10 of the ILM, thereby exhibiting an ability to selectivity stain the ILM. Chromovitrectomy using ICG for dye assisted peeling of ILM gained acceptance for the management of macular holes 11, 12, 13, 14. Its use was later extended to improve visualisation of the glial ERM 15, 16, proliferative membranes of proliferative diabetic retinopathy (PDR) and proliferative vitreoretinopathy (PVR) 17. Controversial reports on the toxic effects of ICG have been published 18. These included Muller cell, RPE 18 and ganglion cell damage; visual field defects and optic atrophy 1, 2,17,18.

2 June 2008 M. Chakrabarti et al. - Vital Dyes 175 Histopathology of the peeled ILM after ICG assisted ILM peel during chromovitrectomy revealed the presence of cellular structures on and under the ILM 19,20. Detection of the presence of retinal elements (plasma membrane of Mullers cells, myofibrocytes, astrocytes) on the peeled ILM raised the issue of retinal damage during peeling. Animal studies and in-vitro experiments indicated a dose dependent ICG mediated toxicity to retinal elements (Mullers cells, ganglion cells, photoreceptors and RPE) 11, The hypotonic ICG solution has been shown to cause osmotic damage to the retinal cells. Exposure to ICG causes damage to the photoreceptors and RPE cells leading on to apoptosis or necrosis due to light induced damage Subretinal injection of ICG in rabbit models may result in RPE damage even in concentration as low as 0.5 mg/ml. There is paucity of published data comparing the effect of ILM peeling with and without the use of ICG. Majority of studies (Table 2) used ICG in higher concentration and this factor could be responsible for the toxicity. We suggest three safety measures when using ICG for ILM peeling. 1. Perform a fast surgical procedure in order to minimize the duration of contact with RPE cells and to minimize the ICG exposure to light from endo illuminator. 2. Use ICG concentrations lower than 0.5 mg/ml to minimize the risk of RPE damage and possible retinal toxicity. 3. Avoid ICG injection direct through the macular hole by any method to control ILM staining (slow injection, use of the 20 gauge, prototype painting brush called vitreo retinal internal limiting membrane color enhancer (VINCE) 31, or by use of perfluorocarbons over the macular hole etc). Infracyanine Green (IfCG) IfCG possesses two well recognized pharmacological differences from ICG, which vouches for its safe profile in chromovitrectomy IfCG is produced in a synthesis mode without sodium iodine. High dose of topical or intraocular iodine can induce severe corneal and retinal damage. 2. the presence of sodium iodine in the ICG solution requires dilution in water resulting in a hypotonic Table 1. Properties of dyes used for chromo vitrectomy

3 176 Kerala Journal of Ophthalmology Vol. XX, No. 2 Table 2. Meta analysis of Articles on ICG use. Sl.No Author Year Procedure Effect Complication 1 Sheidow et al MHS Worse visual acuity when ICG used as adjuvant 2 Gass et al MHS Worse visual acuity when ICG used as adjuvant 3 Ando et al MHS Worse visual acuity when ICG used as adjuvant Optic Atrophy 4 HillenKamp J et al ERM No difference with and without ICG Optic Atrophy 5 Lochead et al MHS No adverse effects 6 Slaughter and Lec MHS No adverse effects 7 Rodrigues and Meyer MHS No difference in anatomic outcome. Worse functional outcome solution of m mol/kg. The iodine free IfCG is dissolved in 5 % glucose solvent generating an iso osmotic solution of m mol /kg 36,37. IfCG in concentrations of 0.5 mg/ml selectively stains the ILM just like ICG and has a much safer profile for intravitreal use. Trypan Blue The anionic hydrophilic azo dye trypan blue has a chemical formula C 34 H 24 N 6 O 14 S 4 and a molecular weight of 960 Daltons. This vital stain traverses the cell membrane in dead cells thereby staining the dead tissues blue. In the 1990s Trypan blue was first used intraocularly to stain the anterior lens capsule to facilitate capsulorrhexis for cataract surgery 38. The use of trypan blue in chromovirectomy is limited to the staining of ERM. It stains the ILM minimally sometimes necessitating repeated application to facilitate visualization. Trypan blue staining of ERM helps mark out its entire extent thereby ensuring complete removal. Clinical studies 39,40 have clearly demonstrated that Trypan blue exerted little or no toxic effects on the retina. Experimental data, however disclosed evidence of retinal toxicity following trypan blue staining. Luke et al 41 reported irreversible damage to the retina after exposure to trypan blue in a bovine model. In contrast to this report Jin et al 42, and Narayanan et al 43, showed that damage to the rodent neurosensory cells was dose dependent and the toxicity could be eliminated at lower doses. A new indication for the use of trypan blue was to stain the edges of an open retinal tear on subretinal administration 44 facilitating its identificaion during vitrectomy. Triamcinolone Acetonide (TA) Triamcinolone Acetonide (TA) is a synthetic insoluble corticosteroid, with a chemical formula C 24 H 31 FO 6 and a molecular weight of 434 daltons. The white steroid suspension has been used for chromovitrectomy since 2003 to visualize the transparent vitreous gel 45 and the posterior vitreous cortex. Guo 46 et al compared the effectiveness of four biostains (triamcinolone acetonide, indocyanine green, trypan blue and sodium fluoroscein) in delineating the vitreous and reported the best visibility and contrast following use of triamcinolone acetonide. In addition triamcinolone crystals get deposited on the ERM and ILM making their identification and peeling easier. The safety of triamcinolone accetonide to the retina has been demonstrated by several invivo and in- vitro studies. Marison VL 46 et al demonstrated that the vehicle (benzyl alcohol) can induce toxicity to the retina in rabbit models and hence the use of preservative free triamcinolone acetonoide is recommended. Patent Blue Patent Blue is a hydrophilic anionic triylmethane dye with a chemical formula of C 27 H 31 N 2 NaO 6 S 2 and a molecular weight of 582 Daltons. This dye has been used to stain the anterior capsule during cataract surgery 17 in a concentration of 0.24 %. Patent blue exhibit minimal systemic toxicity, carcinogenicity and

4 June 2008 M. Chakrabarti et al. - Vital Dyes 177 Table 3. The techniques used for staining the ILM. Sl.No Technique Procedure Advantages Disadvantages 1 Air- filled Technique FAE to remove fluid from Concentrates dye at Higher retinal toxicity. vitreous cavity before dye injection. posterior pole. 2 Fluid- filled technique Inj of dye intravitreously into the Immediate dye washout Less staining as dye is BSS/ RL filled eye. lesser retina toxicity. washed out rapidly. 3 VINCE (Vitreoretinal Painting brush constructed of Selective staining Not patented. Internal limiting a silicone tube connected to a membrane color 20 G metal cannula, Diluted enhancer.) dye in silicone cartridge. mutagenicity 51. Preliminary clinical data demonstrates a moderate affinity of patent blue to ERM and vitreous and a poor affinity to the ILM 52. Toxicity studies revealed conflicting reports on retinal toxicity of patent blue. Luke et al 53 demostrated that patent blue exhibited mild and reversible retinal toxicity, whereas Westermeier et al 54 showed that RPE cells exposed in vitro to patent blue showed no toxicity. Analysis of available data indicate a safer profile for patent blue in comparison to trypan blue, however the exact safe dosage of patent blue for intravitreal injection remains unclear. Brilliant Blue G Briliant blue G, also known as Coomassie or acid blue, is a blue biostain with a chemical formula C 47 H 48 N 3 S 2 O 7 Na and a molecular weight of 854 Daltons. Human and animal studies on the use of BBG for chromovitrectomy and anterior lens capsular staining 55,56 were published in These study results indicate a safe clinical profile for both capsular staining and chromovitrectomy. Absence of corneal endothelial cell damage, no significant retinal pathological changes on light and electron microscopy, no reduction in ERG waves, and no clinical evidence of long term toxicity, were the hallmark results of these studies 55,56,57. The remarkable affinity to the ILM and absence of toxicity makes it a first real alternative to ICG and IfCG. Bromophenol Blue (BrB) (Tetrabromophenosulfonaphthalein) has a molecular weight of 670 Daltons and a chemical formula C 19 H 10 Br 4 O 5 S. In cataract surgery BrB represents an appropriate biostain at a concentration of 1.2 % to stain the anterior lens capsule intensively facilitating easy removal. Preclinical experiments on six novel vital dyes for chromovitrectomy (Light green yellowish, E68, BrB, Chicagoblue, Rhodamine, Rhodulin blau- basic) showed that BrB stained the ERM and ILM better, and was free of toxicity at concentration of 1.2 % and 0.02 % 58. Similar reports have been obtained from histopathological studies 59,60. At a higher concentration of 1 % and 2 % enhanced ILM colouring was possible. Further human clinical data on its safety profile and defining its dosage and indications in chromovitrectomy is awaited. Sodium Fluorescein Sodium Fluorescein is a hydrophilic xanthene dye with a chemical formula C 20 H 10 Na 2 O 5 and a molecular weight of 376 Daltons. Abrams And coworkers 61 in 1978 demonstrated the efficacy of intravitreally injected sodium fluroscein in staining the vitreous thereby aiding its complete removal. The toxicity of sodium fluroscein to the retina has not been reported. Fluoromethalone Acetate (FMA) Fluoromethalone Acetate (FMA) is a synthetic fluorinated glucocorticosteriod with an empirical formula C 24 H 31 FO 5 and a molecular weight of 418 Daltons. Hata et al 62 performed pre-clinical investigations of flurometholone acetate as a potential new adjuvant during vitreous surgery. They found neither reduction in ERG or histological changes following the use of Fluromethalone acetate and concluded that FMA could be used as an alternative to TA during chromovitrectomy.

5 178 Kerala Journal of Ophthalmology Vol. XX, No. 2 Key issues 1. Chromovitrectomy improved the visualisation of preretinal structures in vitreoretinal surgery. 2. Intravitreal injection of dyes appear to be the most feasible approach to stain the vitreous and preretinal tissues. 3. Lower dye concentration and shorter exposure time can limit side effects. 4. Various technique are available to stain ILM (Table 3) Newer vital dyes exhibiting selective staining of preretinal tissue, and no retinal staining are less toxic to the retina. References 1. Rodrigues EB, Meyer CH, Kroll P. Chromovitrectomy: a new field in vitreoretinal surgery Graefes.Arch Clin.Exp. Ophthalmol 2005; 243: Bruk SE, Da Mata AP, Snyder ME, et al. Indocyanine green assisted peeling of internal limiting membrane. Ophthalmology 2000; 107: La Heij EC, Dieudonne SC, Mooy CM et al. Immunohistochemical analysis of the internal limiting membrane peeled with infracyanine green Am.J.Ophthalmol 2005; 140: Wong KL, Hiscott.P, Stanga.P, et al. Trypan blue staining of the internal limiting membrane and epiretinal membranes during vitrectomy; visual results and histopathological findings. Br.J.Ophthalmol 2003; 87: Enaida.H, Hisatomi.T, Goto.Y et al. Preclinical investigations of internal limiting membrane staining and peeling using intravitreal brilliant blue G. Retina 2006; 26: Ozawa.T, Britz GW et al. Bromophenol blue staining of tumors in a rat glioma model. Neurosurgery 2005; 57: Haritoglou.C, Yu A, Freyer W et al. An evaluation of novel vital dyes for intraocular surgery. Invest Ophthalmol Vis Sci 2005; 46: SokolowskiJ, Engeset A. Toxic effect of patent blue on rat lymph node lymphocytes. Lymphology 1974; 7: Jonas JB, Kreissig I et al. Intravitreal Triamcinolone acetonide for treating intraocular exudative, proliferative and neovascular diseases. Prog Retina Eye Res 2005; 24: Desmettre T, Devoiselle JM et al. Fluoresence properties and metabolic features of ICG as related to angiography. Surv Ophthalmol 2000; 45: Rodriguez EB, Meyer CH et al. Intravitreal staining of ILM using ICG in the treatment of macular holes. Ophthalmologica 2005; 219: Sheidow TG, Blinder KJ, Holekamp.N.et al. Outcome results of macular hole surgery: an evaluation of internal limiting membrane peeling with and without indocyanine green. Ophthalmology 2003; 110: Gass CA, Haritoglou C, Schaumberger M et al. Functional outcome of macular surgery with and without indocyanine green assisted peeling of the ILM Graefes Arch clin Exp Ophthalmol 2003; 241: Ando.F, Sasano.K, Ohba N, et al. Anatomic and visual outcomes after ICG assisted peeling of the retinal ILM in Indiopathic macular hole surgery. Am.J. Ophthalmol 2004; 137: Rodrigues EB, Meyer CH, Schmedt JC, Kroll.P. Surgical management of epiretinal membrane with indocyanine green assisted peeling (Letter) Ophthalmologica 2004;218: Hillenkamp J, Saikia P, Herrmann WA et al. Surgical removal of idiopathic ERM with or without the assistance of ICG: a randomised controlled clinical trail. Graefes Arch Clin Exp Ophthalmol 2006; Dec Hiebl W, Gunther B, Meinert H et al. Substances for staining biological tissues: Use of dyes in ophthalmology. Klin Monatsbl Aug in beilkd 2005; 222: Maia.M, Haller JA, Pieramici DJ et al. Retinal pigment epithelial abnormalities after internal limiting membrane peeling guided by ICG staining. Retina 2004; 24: Nakamura.T, Murata T et al. Ultra structure of the vitreoretinal interface following the removal of ILM using ICG. Curr. Eye.Research 2004; 27: Kwok AKH, Li WWY et al. Indocyanine green staining and removal of internal limiting membrane in macular hole surgery: histology and outcome. Am.J.Ophthalmol 2001; 132: Maia.M, Kellner L, de Juan EJr et al. Effects of ICG delivery over the retinal surface and into the subretinal space in rabbits. Retina 2004; 24: Maia M, Margalit E et al. Effect of Intravitreal ICG injection in rabbits. Retina.2004 : 24: Jackson T.L, Hillenkamp J et al. Safety testing of ICG and Trypan blue using retinal pigment epithelium and glial cell cultures. Invest Ophthalmol Vis Sci 2004; 45: Iriyama.A, Uchida.S. et al. Effect of ICG on retinal ganglion cells. Invest Ophthalmol Vis Sci 2004: 45: HO. J, Tsai R J, Chen SN et al Toxic effects of ICG on the RPE related to osmotic effects of the solvent. Am.J. Ophthalmol 2003; Ho JD, Tsai RJ, Chen SN, Chen HC. Removal of sodium from the solvent reduces RPE toxicity caused by ICG: implication for macular hole surgery. Br. J. Ophthalmol 2004;88: Stalmans P, Van Aken EH et al. Toxic effect of ICG on RPE related to osmotic effects of the solvent. Am.J. Ophthalmol 2002; 134: Lochhead J, Jones E, Chui D etal Outcome of ICG assisted ILM peel in macular hole surgery. Eye 2004; 18:

6 June 2008 M. Chakrabarti et al. - Vital Dyes Slaughter.K, Lee IL Macular hole surgery with and without ICG assistance. Eye 2004; 8; Rodrigues EB, Meyer CH Meta analysis of chromovitrectomy with ICG in macular hole surgery. Ophthalmologica 2007; 114: Meyer CH, Rodrigues. EB. et al A novel applicator for the selective painting of pre-retinal structures during vitreo retinal surgery. Graefes Arch. Clin. Exp. Ophthalmol 2005; 243: Kodji Kian L, Richter T et al. Toxic effects of indocyanine green and trypan blue on the retinal pigment epithelium. Graefes Arch. Clin. Exp. Ophthalmol 2005; 243: La Heij EC, Dieudonne SC et al. Immuno histochemical analysis of the ILM peeled with indocyanine green. Am.J. Ophthalmol 2005; 140: Rivett. K, Kruger L, Radloff S et al. Indocyanine green assisted ILM peel in macular hole surgery: does it make a difference? Graefes Arch. Clin.Exp.Ophthalmology 2004; 242; Jackson, TL Vote B, Knight BC et al Safety testing of indocyanine green using retinal pigment epithelial and glial cell cultures. Invest ophthalmol Vis Sci 2004; 45: Ullern.M, Roman S et al. Contribution of indocyanine green to macular hole and epimacular membrane surgery : preliminary study. J.Fr.Ophthalmol 2002; 25: Marmer MF Retinal Detachment from hypertonic intravitreal injection. Invest Ophthalmol Vis Sci 1979; 18: Melles GR, de Waard PW, Pameyer JH, Houdijn Beekhuis W. Trypan blue capsule staining to visualize the capsulorhexis in cataract surgery. J. Cataract Refract Surg 1999; 25 : Veckeneer M, van Overdam K, Monzer J, et al. Ocular toxicity study of trypan blue injected into the vitreous cavity of rabbit eyes. Graefes Arch Clin Exp Ophthalmol 2001; 239 : Vote BJ, Russell MK, Joondeph BC. Trypan blue assisted vitrectomy. Retina 2004; 24 : Luke C, Luke M, Dietlein TS, et al. Retinal tolerance to dyes. Br J Ophthalmol 2005; 89 : Jin Y, Uchida S, Yanagi Y, et al. Neurotoxic effects of trypan blue on rat retinal ganglion cells. Exp Eye Res 2005; 81 : Narayanan R, Kenney MC, Kamjoo S, et al. Trypan blue: effect on retinal pigment epithelial and neurosensory retinal cells. Invest Ophthalmol Vis Sci 2005; 46 : Jackson TL, Kwan AS, Laidlaw AH, Aylward W. Identification of retinal breaks using subretinal trypan blue injection. Ophthalmology 2006; Nov 20 [Epub ahead of print]. 45. Burk SE, Da Maa AP, Snyder ME, et al. Visualizing vitreous using Kenalog suspension. J Cataract Refract Surg 2003; 29 : Guo S, Tutela AC, Wagner R, Caputo AR. A comparison of the effectiveness of four biostains in enhancing visualization of the vitreous. J Pediatr Ophthalmol Strabismus 2006; 43: Kozak I, Cheng L, Mendez T, et al. Evaluationof the toxicity of subretinal triamcinolone acetonide in the rabbit. Retina 2006; 26: Yu SY, Damico FM, Viola F, et al. Retinal toxicity of intravitreal triamcinolone acetonide: a morphological study. Retina 2006; 26: Morrison VL, Koh HJ, Cheng L, et al. Intravitreal toxicity of the kenalog vehicle (benzyl alcohol) in rabbits. Retina 2006; 26: Narayanan R, Mungcal JK, Kenney MC, et al. Toxicity of triamcinolone acetonide on retinal neurosensory and pigment epithelial cells. Invest Ophthalmol Vis Sci 2006; 47: Sokolowski J, Engeset A. Toxic effect of patent blue violet on rat lymph node lymphocytes. Lymphology 1974; 7: Mennel S, Meyer CH, Tietjen A, et al. Patent blue: a novel vital dye in vitreoretinal surgery. Ophthalmologica 2006; 220: Luke C, Luke M, Sickel W, Schneider T. Effects of patent blue on human retinal function. Graefes Arch Clin Exp Ophthalmol 2006; 244: Westermeier R. Sensitive, quantitative, and fast modifications for Coomassie blue staining of polyacrylamide gels. Proteomics 2006; 6: Enaida H, Hisatomi T, Goto Y, et al. Preclilnial investigation of internal limiting membrane staining and peeling using intravitreal brilliant blue G. Retina 2006; 26: Hisatomi T, Enaida H, Matsumoto H, et al. Staining ability and biocompatibility of brilliant blue G: preclinical study of brilliant blue G as an adjunct for capsular staining. Arch Ophthalmol 2006; 124: Enaida H, Hisatomi T, Hata Y, et al. Brilliant blue G selectively stains the internal limiting membrane/ brilliant blue G assisted membrane peeling. Retina 2006; 26: Haritoglou C, Yu A, Freyer W, et al. An evaluation of novel vital dyes for intraocular surgery. Invest Ophthalmol Vis Sci 2005; 46: Schuettauf F, Haritoglou C, May CA, et al. Administration of novel dyes for intraocular surgery: an in vivo toxicity animal study. Invest Ophthalmol Vis Sci 2006; 47: Haritoglou C, Tadayoni R, May CA, et al. Short-term in vivo evaluation of novel vital dyes for intraocular surgery. Retina 2006; 26: Abrams GW, Topping T, Machemer R. An improved method for practice vitrectomy. Arch Ophthalmol 1978; 96: Hata Y, Enaida H, Sassa Y, et al. Preclinical investigation of fluorometholone acetate as a potential new adjuvant during vitreous surgery. Graefes Arch Clin Exp Ophthalmol 2006; Dec 21 [Epub ahead of pint].

Yasser R. Serag, MD Tamer Wasfi, MD El- Saied El-Dessoukey, MD Magdi S. Moussa, MD Anselm Kampik, MD

Microperimetric Evaluation of Brilliant Blue G- assisted Internal Limiting Membrane Peeling By Yasser R. Serag, MD Tamer Wasfi, MD El- Saied El-Dessoukey, MD Magdi S. Moussa, MD Anselm Kampik, MD The internal