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Inadvertent corneal stromal staining by trypan blue following Descemet's membrane endothelial keratoplasty

Published:November 23, 2018DOI:https://doi.org/10.1016/j.jcjo.2018.10.002
      Trypan blue is an azo dye solution that effectively stains basement membranes such as the anterior lens capsule and Descemet's membrane.
      • Sinha R.
      • Vajpayee R.B.
      • Sharma N.
      • Titiyal J.S.
      • Tandon R.
      Trypan blue assisted descementorhexis for inadvertently retained Descemet's membranes after penetrating keratoplasty.
      In Descemet's membrane endothelial keratoplasty (DMEK), where the host Descemet's membrane and corneal endothelium are initially removed, trypan blue is used to stain the donor graft before injection to provide visibility during the unscrolling process in the anterior chamber. Trypan blue can also be injected after the descemetorrhexis and before graft injection to visualize any irregular tags or retained Descemet's membrane, both of which may increase the risk for graft detachment.
      • Majmudar P.A.
      • Johnson L.
      Enhancing DMEK success by identifying optimal levels of trypan blue dye application to donor corneal tissue.
      DMEK is performed for Fuchs’ endothelial corneal dystrophy (FECD), which is characterized by thickening of Descemet's membrane, progressive corneal endothelial cell loss, and deposition of extracellular matrix proteins in the form of guttae.
      • Elhalis H.
      • Azizi B.
      • Jurkunas U.V.
      Fuchs endothelial corneal dystrophy.
      Lattice corneal dystrophy (LCD) is a stromal dystrophy characterized by radially oriented linear amyloid opacities in the anterior stroma leading to vision loss and photophobia.
      • Dark A.J.
      • Thomson D.S.
      Lattice dystrophy of the cornea: a clinical and microscopic study.
      In a MEDLINE search, no cases of concurrent FECD and LCD could be found. We present a novel case of inadvertent stromal staining by trypan blue after DMEK in a patient with both FECD and clinically presumed LCD.

      Case presentation

      A 77-year-old male presented with LCD and guttae in his amblyopic right eye. His best spectacle corrected visual acuity (BSCVA) was counting fingers at 3 feet, endothelial cell count (ECC) was 1401/mm2, and central corneal thickness (CCT) was 601 µm. The patient underwent uncomplicated DMEK surgery with an 8.25 mm trypan blue-stained graft within an 8.50 mm descemetorrhexis. Intracameral trypan blue was injected into the anterior chamber after the descemetorrhexis to ensure no residual tags of Descemet's membrane remained. At the first postoperative follow-up appointment, there was notable diffuse blue staining of amyloid LCD deposits at the interface between the host stroma and the donor graft (Fig. 1). This deposition of trypan blue did not affect vision and has remained for 6 months following the DMEK surgery. At the most recent follow-up visit, BSCVA had improved to 20/100, ECC improved to 2353/mm2, and CCT was 593 µm. The patient's fellow eye had undergone Descemet's stripping automated endothelial keratoplasty 9 years prior with pathology confirmed findings of “endothelial accumulation consistent with Fuchs’ dystrophy.”
      Fig. 1.
      Fig. 1Slit lamp photograph of the patient's right eye at the 1-day postoperative visit after DMEK surgery. Significant trypan blue staining of lattice amyloid deposits at the interface between the host stroma and donor DMEK graft is evident.

      Discussion

      Trypan blue staining has demonstrated safe and efficacious results when utilized in corneal transplantation procedures. Majmudar and Johnson determined that staining a DMEK graft with trypan blue dye (0.06% or 0.15%) for up to 5 minutes increases visibility of the donor tissue for a sufficient period of time (110 minutes) with no decreased ECC.
      • Majmudar P.A.
      • Johnson L.
      Enhancing DMEK success by identifying optimal levels of trypan blue dye application to donor corneal tissue.
      Five cases of inadvertent corneal stromal staining by trypan blue have been published, one of which was after a corneal transplantation procedure. In 2014, a retrospective case series by Farooq et al. described 4 cases of stromal staining in patients with LCD. One patient with a central stromal scar and thick ropy lattice lines underwent a deep anterior lamellar keratoplasty procedure where trypan blue was used to aid in removal of the Descemet's membrane from the donor cornea.
      • Farooq A.V.
      • Tu E.Y.
      • Djalilian A.R.
      • Traish A.S.
      • Hou J.H.
      Persistent staining of lattice lines after intraoperative trypan blue use in patients with lattice corneal dystrophy.
      Persistent trypan blue staining of peripheral lattice lines was noted in the host stroma at postoperative day 176.
      • Farooq A.V.
      • Tu E.Y.
      • Djalilian A.R.
      • Traish A.S.
      • Hou J.H.
      Persistent staining of lattice lines after intraoperative trypan blue use in patients with lattice corneal dystrophy.
      It has been postulated that persistent staining of peripheral lattice lines is consistent with trypan blue's affinity for amyloid deposits,
      • Hu J.
      • El-Fakahany E.E.
      An artifact associated with using trypan blue exclusion to measure effects of amyloid beta on neuron viability.
      and that a violation of the Descemet's membrane must be present as trypan blue is unable to penetrate intact basement membranes.
      • Farooq A.V.
      • Tu E.Y.
      • Djalilian A.R.
      • Traish A.S.
      • Hou J.H.
      Persistent staining of lattice lines after intraoperative trypan blue use in patients with lattice corneal dystrophy.
      The remaining 3 cases by Farooq et al. were also patients with LCD, but occurred after cataract surgery where trypan blue was used to stain the anterior capsule.
      • Farooq A.V.
      • Tu E.Y.
      • Djalilian A.R.
      • Traish A.S.
      • Hou J.H.
      Persistent staining of lattice lines after intraoperative trypan blue use in patients with lattice corneal dystrophy.
      The fifth case of inadvertent stromal staining was described by Jhanji et al. in a patient after cataract surgery.
      • Jhanji V.
      • Agarwal T.
      • Titiyal J.S.
      Inadvertent corneal stromal staining by trypan blue during cataract surgery.
      Trypan blue was accidentally injected intrastromally in an attempt to stain the anterior lens capsule. In this case, the patient did not have LCD, and the significant postoperative stromal straining was attributed to improper wound construction, inability to locate the entry wound, and use of a blunt-tipped cannula.
      • Jhanji V.
      • Agarwal T.
      • Titiyal J.S.
      Inadvertent corneal stromal staining by trypan blue during cataract surgery.
      In summary, we present the first case of a patient with concomitant FECD and LCD. In addition, this is the first case of a patient with inadvertent corneal stromal staining by trypan blue after a DMEK procedure. Intraoperative removal of Descemet's membrane allowed trypan blue to stain exposed posterior stromal amyloid deposits but was not visually significant. Ophthalmologists should be aware that using trypan blue intraoperatively to improve Descemet's membrane visualization during a corneal transplant procedure in a patient with LCD may lead to persistent corneal stromal staining.

      Disclosures

      Dr. David Rootman has received prior honoraria from Johnson & Johnson. Dr. Clara C. Chan has received prior honoraria and/or research funding from Alcon, Allergan Inc, Bausch + Lomb, Johnson & Johnson, Labtician, Santen Pharmaceutical, Shire Plc, and TearLab Corporation. For the remaining authors, no conflicts of interest were declared.

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