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Chromovitrectomy: an Update Review Article Chromovitrectomy: an Update Flora Hernández, MD; Natalia Alpizar-Alvarez, MD; Lihteh Wu, MD Instituto de Cirugia Ocular, San José, Costa Rica Adequate visualization and identification of the posterior hyaloid, epiretinal membranes and the internal limiting membrane are of paramount importance in modern vitreoretinal surgery. “Chromovitrectomy” is a term used for describing the vital dyes use in order to stain these transparent tissues and facilitate their manipulation during vitreous surgery. This article reviews the indications, applications and characteristics of vital dyes in vitreoretinal surgery. Various dyes are currently being used in routine clinical procedures, however the ideal staining agent has not yet been found. Any dye which is injected intravitreally has the potential to become toxic. Triamcinolone acetonide is used to highlight the vitreous and is particularly beneficial in determining the attachment of the posterior hyaloid to the underlying retina. Trypan blue stains epiretinal membranes and facilitates their complete removal. Both indocyanine green and brilliant blue G stain the internal limiting membrane properly, however concerns over indocyanine green toxicity have made surgeons switch to brillliant blue G as a safer alternative. Keywords: Chromovitrectomy; Trypan Blue; Indocyanine Green; Brilliant Blue G; Internal Limiting Membrane; Posterior Hyaloid; Epiretinal Membrane J Ophthalmic Vis Res 2014; 9 (2): 251-259. Correspondence to: Lihteh Wu, MD. Calle 28 Avenida 2, Diagonal Sala Garbo, San José P.O. Box 144-1225 Plaza Mayor, San José, Costa Rica; Tel: +50 6 2256 2134, Fax: +50 6 2220 3502; e-mail: [email protected] Received: July 17, 2013 Accepted: August 18, 2013 The vitreous is composed of 98% water with the the strongest adhesions in the retinal periphery. remainder consisting of macromolecules such Epiretinal membranes (ERMs), macular holes as collagen fibrils and hyaluronan. Through (MHs) and vitreomacular traction syndrome aging, the vitrous undergoes several biochemical (VMTS) may develop if strong adhesions are changes leading to progressive liquefaction present in the macula.1,2 Release of this traction of the vitreous gel which eventually results by removal of the offending tissues has been in a posterior vitreous detachment (PVD). advocated as a solution for these conditions. An anomalous PVD may occur when there The posterior hyaloid, ERM and internal is no clean separation along the vitreoretinal limiting membrane (ILM) are three tissues interface.1 Surgical, histopathological and which vitreoretinal surgeons encounter major imaging advances over the past two decades difficulties in dealing with, since these tissues have demonstrated that traction along the are usually thin, transparent and difficult to vitreoretinal interface induced by an anomalous visualize. PVD plays an important role in several diseases. Staining of these transparent tissues with Depending on the position of the strongest vital dyes during vitrectomy greatly simplifies vitreoretinal adhesion, an anomalous PVD the procedure. “Chromovitrectomy” is a term may evolve into several clinical conditions.1 employed to describe the use of vital dyes in For instance, a tear or detachment ensues from order to stain transparent tissues and facilitate JOURNAL OF OPHTHALMIC AND VISION RESEARCH 2014; Vol. 9, No. 2 251 Chromovitrectomy; Hernández et al their manipulation during vitreous surgery.3 Triamcinolone acetonide (TA) is a well- Over the past decade, substances such as tolerated corticosteroid used for the treatment of indocyanine green (ICG), trypan blue (TB) diseases such as uveitis, diabetic macular edema and brilliant blue G (BBG) have been used in (DME) and retinal vein occlusions. Once TA is vitrectomy with confirmed staining capabilities, injected into the vitreous cavity, its particles but concerns over their retinal toxicity still adhere to the vitreous gel facilitating visualization remain.4 and identification (Figures 1 and 2).7 In addition, The toxic effects of any vital dye depends on using TA may improve vitrectomy outcomes by its concentration, the osmolarity of the solution, reducing blood retinal barrier breakdown and dye exposure time and illumination time. To preretinal fibrosis. Currently this is the most avoid toxicity a number of recommendations widely used technique to visualize the posterior should be considered: the lowest concentration hyaloid.4,6 A comparative study of fluorescein, that will achieve staining should be used and dilutions with physiological osmolarities must rigorously be attained. The light pipe should remain far from the macula to avoid light toxicity and the photodynamic effect of the dye.4 Since the bare retinal pigment epithelium (RPE) in the floor of an MH may get in contact with the dye and sustain potential RPE toxicity, covering the hole with blood, viscoeslastic or perfluorocarbon liquid is suggested. Posterior Hyaloid Traction exerted by the posterior hyaloid has been implicated in the pathogenesis of several conditions such as proliferative vitreoretinopathy (PVR), proliferative diabetic retinopathy (PDR), penetrating eye trauma and macular holes. Therefore the surgical goal of any vitrectomy should be posterior hyaloid separation and Figure 1. Triamcinolone acetonide particles adhere to the removal of the vitreous as much as possible. vitreous gel making its visualization and identification Despite the development of surgical techniques, easy. at times the surgeon may not be confident that the posterior hyaloid has actually been removed. In conditions characterized by breakdown of the blood retinal barrier such as PVR, uveitis, retinal vein occlusions and diabetic retinopathy, an intravenous injection of fluorescein sodium 1 to 2 days prior to the scheduled vitrectomy stains the vitreous green facilitating its identification.5 Blood in the vitreous cavity coats the vitreous by adhering to its collagen fibrils making the normally transparent vitreous opaque and easier to visualize for removal. In eyes with no pre- existing vitreous hemorrhage, a small amount of autologous blood may be injected into the Figure 2. The adherence of triamcinolone acetonide 6 particles demonstrates that the posterior hyaloid is still vitreous cavity to coat the vitreous. attached at the posterior pole. 252 JOURNAL OF OPHTHALMIC AND VISION RESEARCH 2014; Vol. 9, No. 2 Chromovitrectomy; Hernández et al ICG, TA and TB concluded that the vitreous was best highlighted by TA.8 A recent study demonstrated that a 20% solution containing the natural dyes lutein and zeaxanthin, precipitates on the vitreous surface staining it orange.9 Epiretinal Membranes Over the past two decades owing to refinements in instrumentation and surgical techniques, ERM removal has been the typical indication for macular surgery. Clinically significant ERMs range from dense opaque tissues to Figure 3. Intraoperative photograph of an epiretinal fine transparent membranes. The transparent membrane stained with trypan blue. (Courtesy of Mauricio Maia, MD) ERMs pose a challenge even to experienced surgeons since incomplete removal of the ERM Internal Limiting Membrane is implicated in post-surgical recurrences10 which have been reported in up to 21% of The ILM is made of the basement membrane of cases.11-13 Staining of the transparent ERM allows Müller cells representing an interface between identification of its entire extent and facilitates the retina and the vitreous. The significance of its visualization and complete removal. ILM peeling is in achieving closure of large and ERMs may also occur in the context of chronic idiopathic MHs.19 Tangential traction PVR. Surgical success depends on complete from the ILM plays a key role in the pathogenesis removal of the ERMs. Staining of these ERMs of MH. In a post-mortem examination, the eye facilitates surgery by improving visualization, with successful MH closure was characterized characterization of the ERM as diffuse or focal, by an area of absent ILM surrounding the sealed and confirmation that the tissue requiring to MH.20 In contrast in another patient that had a be peeled is indeed an ERM and not swollen re-opened MH, histopathological examination nerve fiber layer.14 revealed an ERM with ILM surrounding the Among the commercially available agents, open MH suggesting that traction from the ILM TB is the dye of choice for ERM peeling.4,15 was partly responsible for recurrence.21 This dye binds to degenerated cell elements In other conditions such as DME and and does not stain live cells or tissues with ERM, ILM peeling has remained controversial. intact cell membranes since there is no uptake Surgical specimens often show fragments of the of the dye. As ERMs are mostly composed of ILM interspersed among the ERM.22-24 Breaks dead glial cells, TB exhibits strong affinity for in the ILM may provide access to the macular them (Figure 3). Cataract surgeons have long surface for cellular elements, thus ILM peeling used TB to stain the anterior capsule during may reduce the risk of recurrence following phacoemulsification.16 ERMs stain prominently ERM removal. Even in cases with complete ERM with 0.15% TB which is a relatively safe removal, recurrences may occur. Therfore by concentration.15 Histopathological analysis removing the ILM as well, the surgeon can be of excised ERM showed no retinal cells on assured that the ERM has been entirely removed. the retinal side of the ERM and no signs of Thus ILM peeling has been proposed as a means apoptosis. No RPE defects
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