Clear corneal incision with trypan-blue–coated blades

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<ul><li><p>level of the anterior capsulorhexis or aimed toward the posteriorcapsule while the IOL is fully injected into the capsular bagwith the cartridge tip remaining bevel up. Both haptics are nowposterior to the optic and consistently unfold under the anteriorcapsule edge, with the IOL completely in the capsular bag.</p><p>DISCUSSION</p><p>The S-fold method differs from the standard technique in2 ways: placing the IOL in the S configuration before insertioninto the cartridge and injecting the IOL with the bevel up. Thefinal optichaptic configuration is the manufacturers intendedorientation of the mirror image of S (Figure 4) while the hap-tics unfold posterior to the optic. This yields 2 main advan-tages. First, there is no concern about the haptics unfoldingclose to the corneal endothelium. Second, as long as the opticis delivered under the anterior capsular rim, the haptics willunfold in the capsular bag without the need for more IOL ma-nipulation. Simply placing the haptics beneath the optic on IOLinsertion to position them posteriorly should not be done. Thiscould lead the injector plunger to pass beneath the optic andentangle the haptics, causing distortion to the optichapticjunction.1</p><p>We have now transitioned to this insertion technique andhave had no related complications such as wound enlargementor posterior capsular bag violation. While the standard insertiontechnique is effective, this novel folding and insertion methodprovides an alternative approach that enhances proper hapticplacement with less risk to the corneal endothelium.</p><p>REFERENCE</p><p>1. Dada T. Difficulties during insertion of the AcrySof single-piece IOL</p><p>[letter]. J Cataract Refract Surg 2004; 30:2645</p><p>Figure 4. Optic and haptics resembles a mirror image of S.</p><p>CORRESPONDENCE</p><p>J CATARACT REFRACT SURGClear corneal incisionwith trypan-bluecoated blades</p><p>Ozcan Kaykcoglu, MD</p><p>It is sometimes difficult to find the exact location of a clear cornealside-port incision during cataract or glaucoma surgery, especiallyin an eye with arcus senilis or corneal edema. Side-port locationsare found by a trial-and-error approach if there is not enough vi-sual feed back. However, estimating the configuration and widthof a clear corneal phaco incision is not easy, yet it is an importantdeterminant of whether an intraocular lens (IOL) can be insertedthrough the incision and whether a suture will be necessaryafterward.</p><p>Trypan blue dye is widely used to stain the anterior lens cap-sule as well as corneal incisions in keratoplasty and corneal refrac-tive procedures.14 I observed that in cataract cases in whichtrypan blue was used to visualize the anterior capsule, the cornealincisions were also stained. However, surgeons are reluctant to usetrypan blue in all cataract cases because of concerns about toxicity.I describe a method to stain corneal incisions without introducingthe dye into the anterior chamber.</p><p>TECHNIQUE</p><p>In the first version of this technique, an MVR blade tip wasdipped in trypan blue dye 0.4% just before a clear corneal stab in-cision wasmade. The corneal incision wasmarked with the trypanblue dye superficially on the epithelial side, without visible pene-tration of the dye into the anterior chamber. Effort was made tokeep the dye on the blade tip by mixing the dye with an ophthal-mic viscosurgical device (OVD).5 This maneuver was not veryuseful because the trypan blueOVD mixture slipped down theblade. The next version of the technique included dropping try-pan blue dye on the corneal entry site by a cannula at the timethe stab incision wasmade, which did not work effectively. Finally,adequate staining of the entry wound was achieved by coating theblade tip preoperativelydplacing the dye on the blade about 15minutes before surgery. This resulted in a coating of dried dye par-ticles and trypan blue on the blade, which stained the cornealstroma instead of the epithelial side only (Figure 1). Visualizingthe incision tract facilitated the introduction of instruments intothe anterior chamber during the rest of the operation, resultingin less tissue manipulation.</p><p>A 3.0 mm/3.2 mm phaco incision blade tip was then coatedwith trypan blue. This made it possible to see and adjust the inci-sion width with the assistance of the dye. Fluid outflow from theincision and possibly the mechanical effect of phaco tip move-ments during the surgery also facilitated visualization of the inci-sion. Using trypan-bluecoated blades (3.0 or crescent blades) toenlarge the phaco incision was useful to estimate the width andshape of the corneal incision before IOL insertion.</p><p>DISCUSSION</p><p>For the past 6 months, I have used trypan-bluecoated bladesin most cataract cases and have not experienced any problems as-sociated with it during surgery or postoperatively. There is almostno dye in the incision tract after the first few days. In rare cases,I observed shiny crystals at the incision site. I have also usedtrypan-bluecoated blades to create a side-port incision for- VOL 33, FEBRUARY 2007 351</p></li><li><p>instructions, particularly the limitations placed on activity. Thereare no evidence-based recommendations regarding the effect ofeveryday tasks on corneal wound integrity. We plan to studythis issue by observing healthy postoperative patients before andafter they perform various activities. In preparation, we surveyedthe current practice at academic medical centers in the UnitedStates.</p><p>Few studies address the appropriateness of specific proscrip-tions after phacoemulsification. One study of wound dehiscenceafter extracapsular cataract extraction found that dehiscencewas caused by direct pressure or trauma to the eye in all casesand by simple bending in no cases.1 A 2001 survey of the NationalHealth Service in Britain found that activity limitations after pha-coemulsification varied significantly among centers and sur-geons.2 The external pressure that must be applied to varioustypes and sizes of clear corneal and limbal incisions to causewound collapse and fluid leakage has been studied in the cadavermodel.35 However, the daily activities that place patients at riskfor exceeding this pressure are unknown.</p><p>SURVEY RESULTS</p><p>A survey was sent to cataract surgeons at 14 academic med-ical centers in all areas of the U.S. (Table 1). Thirteen surveyswere returned. Instructions regarding postoperative pain control,personal hygiene, and eye shield use were similar at all centers.Acetaminophen (Tylenol) was prescribed for pain; patients weretold to call the medical center if they experienced severe pain.Eye-shield use was prescribed at most centers until the officevisit on postoperative day 1 and then for 1 week at night only.Normal personal hygiene routines including hair washing wereresumed 1 to 3 days postoperatively at all centers. Antibioticand steroid regimens were similar. Ten centers prescribed third-or fourth-generation fluoroquinolones 4 times a day for 1 week</p><p>Table 1. Academic medical centers surveyed.</p><p>Name Location</p><p>Bascom Palmer Eye Institute Miami, FloridaBeth Israel Deaconess Medical</p><p>CenterBoston, Massachusetts</p><p>Doheny Eye Institute Los Angeles, CaliforniaDuke University Eye Center Durham, North CarolinaIowa University Iowa City, IowaIndiana University Department</p><p>of OphthalmologyIndianapolis, Indiana</p><p>Veterans AdministrationsHospitals</p><p>Jamaica Plain, MassachusettsTogus, Maine</p><p>Jules Stein Eye Institute Los Angeles, CalforniaW.K. Kellogg Eye Center Ann Arbor, MichiganMassachusetts Eye and Ear</p><p>InfirmaryBoston, Massachusetts</p><p>University of California atSan Francisco</p><p>San Francisco, California</p><p>Washington UniversityEye Center</p><p>St. Louis, Missouri</p><p>Wilmer Eye Institute Baltimore, Maryland</p><p>CORRESPONDENCEtrabeculectomy. This is particularly useful as it is difficult to findthe side-port incision in a hypotonic eye.</p><p>My suggestion is to manufacture ready-to-use surgical bladesevenly coated with trypan blue dye particles. Alternatively, it maybe possible to manufacture surgical blades with grooves to holdthe dye so it can be distributed into the wound lips evenly. I be-lieve the technique can be helpful in marking any clear cornealincision.</p><p>REFERENCES</p><p>1. Melles GRJ, deWaard PWT, Pameyer JH, Beckhuis WH. Trypan blue cap-</p><p>sule staining to visualize the capsulorhexis in cataract surgery. J Cata-</p><p>ract Refract Surg 1999; 25:79</p><p>2. Roos JC, Kerr Muir MG. Use of trypan blue for penetrating keratoplasty.</p><p>J Cataract Refract Surg 2005; 31:18671869</p><p>3. Pangtey MS, Panda A. Deep lamellar keratoplasty with trypan blue</p><p>intrastromal staining [letter]. J Cataract Refract Surg 2003; 29:45</p><p>4. Balestrazzi E, Balestrazzi A, Mosca L, Balestrazzi A. Deep lamellar kerato-</p><p>plasty with trypan blue intrastromal staining. J Cataract Refract Surg</p><p>2002; 28:929931</p><p>5. Kayikicioglu O, Erakgun T, Guler C. Trypan blue mixed with sodium hy-</p><p>aluronate for capsulorhexis [letter]. J Cataract Refract Surg 2001; 27:970</p><p>Instructions after routinephacoemulsification cataract surgerywith clear corneal incision</p><p>Christine Shortsleeve Ament, MD,Bonnie An Henderson, MD</p><p>Instructions after uneventful clear corneal phacoemulsificationcataract surgery vary greatly among surgeons. We think patientswould benefit from standardization and rationalization of these</p><p>Figure 1. Side-port incision with an MVR blade coated with trypan</p><p>blue dye.J CATARACT REFRACT SURG - VOL 33, FEBRUARY 2007352</p><p>Clear corneal incision with trypan-blue-coated bladesTechniqueDiscussionReferences</p></li></ul>