Accidental Subretinal Brilliant Blue G Migration During Internal Limiting Membrane Peeling Surgery

Abstract

rilliant blue G (BBG) selectively stains the internal limiting membrane (ILM), improving visualization during ILM peeling. 1 Despite controversy about the safety profile of the dye, BBG has been widely used intraoperatively in many countries. 1 Accidental delivery of dyes into the subretinal space is a well-known complication associated with macular surgical procedures. 2-5 In this report, we describe the outcomes of retinal function and structure during 2 years in a patient after epiretinal membrane (ERM) and ILM peeling with accidental migration of BBG into the subretinal space at the macular area. Report of a Case A man in his 60s presented with decreased visual acuity and progressive metamorphopsia for 6 months in his right eye. The patient had a history of glaucoma and had been monitored in our clinic for the past 5 years with well-controlled intraocular pressure and stable visual field defects. Examination demonstrated a best-corrected visual acuity (BCVA) of 20/70 OD and 20/20 OS. Intraocular pressure was 13 mm Hg and 12 mm Hg, respectively. Slitlamp examination demonstrated mild nuclear sclerosis in each eye. Dilated ophthalmoscopic examination demonstrated thinning of the neuroretinal rim in each eye and an ERM with vascular tortuosity in the right eye. Optical coherence tomography (Heidelberg retinal angiography; Heidelberg Engineering) of the right eye was notable for an ERM and a central subfield macular thickness (CSMT) of 596 μm (Figure 1). Multifocal electroretinography (mfERG) (Espion E2; Diagnosys LLC) of the right eye revealed amplitude and implicit times within the reference range (Figure 2). Surgical Procedure Phacoemulsifications with posterior chamber intraocular lens (MA60AC +22.5 diopters; Alcon Inc) placement, followed by 23-gauge pars plana vitrectomy (Accurus system; Alcon/ Grieshaber), were performed on the right eye. Three nonvalved trocars (Alcon Inc) were placed, and triamcinolone acetonide, 0.4 mg, in 0.1 mL (Ophthalmos) was used to stain the IMPORTANCE This case report describes a man who developed retinal changes in his right eye associated with brilliant blue G migration into the subretinal space during 2 years of follow-up. OBSERVATION The patient's best-corrected visual acuity in the right eye was 20/70 before surgery, and it improved to 20/25 at 1 year after surgery. Fluorescein angiography showed staining during the late phase in the central macula at all follow-up visits after surgery. Multifocal electroretinography demonstrated normal amplitude and implicit times before surgery but decreased amplitudes and increased implicit times in at least 5 contiguous hexagons after surgery on all 3 examinations performed during the 2-year follow-up period. These functional changes were not topographically correlated with the area of fluorescein staining or with the internal limiting membrane peeled area, but were matched to the area where brilliant blue G accidentally entered the subretinal space. Microperimetry demonstrated reduced retinal threshold sensitivity, particularly in areas...

Recurrence rate and need for reoperation after surgery with or without internal limiting membrane removal for the treatment of the epiretinal membrane

“…This may, therefore, lead to increased surgical risk. Some studies have shown that dye injection might result in migration of the dye into the subretinal space [ 20 ]. In our study, this complication occurred in two eyes (4%).…”

Differential autophagic effects of vital dyes in retinal pigment epithelial ARPE-19 and photoreceptor 661W cells

“…BBG, it was claimed, provided a good staining to the ILM and was not toxic in experimental studies and a case series in humans [ 15 ]. However, recent reports showed a selective toxicity to photoreceptors related to BBG after intravitreal injection in rabbit eyes and RPE changes on fluorescein angiography, as well as macular damage following accidental subretinal dye injection in humans [ 16 – 20 ]. Another report of the intraocular safety of ICG, TB, Evans blue (EB), and BBG on ARPE-19 cell lines and murine retinal ganglion/Müller glial (RGC) primary cell cultures showed that all dyes demonstrated relatively safe viability profiles in both cell lines at surgically relevant concentrations and times.…”

New Brilliant Blue G Derivative as Pharmacological Tool in Retinal Surgery

“…The ideal dye for vitreoretinal surgery should be a high grade of purity compound, in order to avoid any potential interference during surgery. It has been reported that retinal damage can occur after treatment with vital dyes, and this is linked to the passive absorption of molecules in the retinal layers underneath the ILM (Kanda et al, 2004;Kawahara et al, 2007;Ueno et al, 2007;Maia et al, 2009;Ejstrup et al, 2012;Savary and Kodjikian, 2014;Almeida et al, 2015;Hurst et al, 2017) (Figure 1). On the basis of predicted ADME properties of PBB ® the risk of iatrogenic retinal damage is very low, also due to poor absorption into the retina.…”