ruptured retinal arterial macroaneurysm was noted alongthe inferotemporal vascular arcade. Subretinal and in-traretinal hemorrhage and subretinal fluid extended intothe fovea. The vitreous hemorrhage had reabsorbed. TheWatzke–Allen test was positive. Optical coherence tomog-raphy examination confirmed the presence of a full-thickness macular hole and of subretinal hemorrhageextending into the fovea (Figure 1B). Because of thepresence of submacular hemorrhage, we decided to followthe patient before recommending surgery for macular holerepair. Two months later, there was partial resolution ofthe subretinal hemorrhage (Figure 1, C and D). A fluores-cein angiography study was performed, confirming thepresence of the retinal arterial macroaneurysm and of thefull-thickness macular hole (Figure 1E). She then under-went a standard three-port pars plana vitrectomy, alongwith peeling of the internal limiting membrane andinternal tamponade with 15% hexafluoroethene (C2F6)gas. Anatomic closure of the macular hole was achievedafter the operation and was confirmed by optical coherencetomography examination (Figure 1F). Two months aftersurgery, her vision had improved to 20/100 despite thepresence of a 2–3� nucleus sclerosis cataract.

This is the fourth case report of macular hole associatedwith a ruptured retinal arterial macroaneurysm. Coluc-ciello and Nachbar4 reported a 67-year-old female patientwho developed a full-thickness macular hole about 5months after she was diagnosed with a ruptured retinalarterial macroaneurysm. At vitrectomy, they found athickened, taut posterior vitreous cortex and hypothesizedthat tangential or anteroposterior vitreous traction on thefovea from a contracted posterior vitreous cortex (whichcould have been induced by the vitreous hemorrhage)could have contributed to the formation of the macularhole. Mitamura and colleagues5 reported of two patientswho developed a full-thickness macular hole after havingbeen diagnosed with retinal arterial macroaneurysm, oneafter laser treatment of the macroaneurysm. In both cases,they found absence of a posterior vitreous detachment anda taut posterior vitreous cortex, firmly adherent to theretina. In all these three cases, there was no posteriorvitreous detachment, and the macular hole was diagnosedas a stage III. In addition, the formation of the macularhole was noted after there had been almost total reabsorp-tion of the subretinal and intraretinal hemorrhage causedby the macroaneurysm.

To our knowledge, this is the first case report of a stageIV macular hole in association with a retinal arterialmacroaneurysm. Our patient differs from the previouslyreported cases in that she had a total posterior vitreousdetachment at the time of the diagnosis of the macularhole. She also had a considerable amount of subretinalhemorrhage. A possible explanation for the formation ofthe macular hole in this case is that a posterior vitreousdetachment was induced by the vitreous hemorrhage,causing the formation of an epiretinal membrane and a

macular hole. Another explanation is that the detachmentprecipitated the vitreous hemorrhage from the macroan-eurysm. A final possibility is that of structural damage tothe retina from intraretinal and subretinal hemorrhage.We decided to wait for a partial resolution of the subretinalhemorrhage before performing macular hole surgery, al-though earlier surgery associated with evacuation of thesubmacular hemorrhage was another option.

In conclusion, this case report expands our knowledge ofthe association of macular hole and ruptured retinalarterial macroaneurysm. We reported successful surgicalclosure of the macular hole with improvement of vision.

REFERENCES

1. Flynn HW. Macular hole surgery in patients with proliferativediabetic retinopathy. Arch Ophthalmol 1994;112:877–878.

2. Cohen SM, Gass JDM. Macular hole following severe hyper-tensive retinopathy. Arch Ophthalmol 1994;112:878–879.

3. Munoz FJ, Rebolleda G, Cores FJ, Bertrand J. Congenitalretinal arteriovenous communication associated with a fullthickness macular hole. Acta Ophthalmol 1991;69:117–120.

4. Colucciello M, Nachbar JG. Macular hole following rupturedretinal arterial macroaneurysm. Retina 2000;20:94–96.

5. Mitamura Y, Terashima H, Takeuchi S. Macular hole forma-tion following rupture of retinal arterial macroaneurysm.Retina 2002;22:113–115.

Epiretinal Membrane Surgery Assistedby Trypan BlueManuel Perrier, MD, andMikael Sebag, MD, FRCP(C)

OBJECTIVE: To evaluate patient outcome followingepiretinal membrane surgery using trypan blue to facili-tate visualization and delamination.DESIGN: A retrospective noncomparative review of 23patients.METHODS: Patients underwent a three-port pars planavitrectomy with delamination using trypan blue 0.06%.RESULTS: The median preoperative visual acuity was20/100. The median postoperative visual acuity was20/60. Seventeen patients (74%) improved their visualacuity by at least 2 chart lines. No adverse reactionrelated to trypan blue was observed up to 1 year postop-eratively.

Accepted for publication Dec 10, 2002.InternetAdvance publication at ajo.com Dec 11, 2002.From the Ophthalmology Department, Centre Hospitalier Universite

de Montreal—Pavillon Notre-Dame, Montreal, Quebec, Canada.Inquiries to Manuel Perrier, MD, or Mikael Sebag, MD, Ophthalmol-

ogy Department, Centre Hospitalier Universite de Montreal—PavillonNotre-Dome, 1560 Sherbrooke Est, Montreal, Quebec, Canada H2L4M1;e-mail: perrier.manuel@sympatico.ca

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CONCLUSIONS: Trypan blue staining of the epiretinalmembrane facilitated visualization and delaminationwithout any signs of toxicity. (Am J Ophthalmol 2003;135:909–911. © 2003 by Elsevier Inc. All rightsreserved.)

THE PURPOSE OF THIS STUDY WAS TO EVALUATE PA-

tient outcome following trypan blue–assisted epiretinalmembrane surgery. Our study is a noncomparative retro-spective review of a consecutive series of patients who hadundergone epiretinal membrane surgery using trypan blueto assist in visualization. All procedures were performed bythe same vitreoretinal specialist who had extensive expe-rience at removing the epiretinal membrane without theuse of trypan blue. For the study, 26 patients charts werereviewed; 3 patients were excluded because of a history ofa rhegmatogenous retinal detachment involving the mac-ula.

The surgical procedure for epiretinal membrane repairincluded a standard three-port pars plana vitrectomy usingthe Alcon Accurus system (Alcon Laboratories, FortWorth, Texas, USA). A total of 0.5 to 1 ml of trypan blue0.06% (Visionblue, DORC International, Zuidland, TheNetherlands) was injected under continuous infusion over

the posterior pole under direct visualization, staining theepiretinal membrane and the internal limiting membrane.The epiretinal membrane was then incised and removedwith an intraocular forceps, as was the internal limitingmembrane when residual traction was noted. No specimenwas sent for histologic confirmation.

The main information gathered from the hospital chartswere the patients’ preoperative and postoperative visualacuity as well as clinical signs of postoperative macularatrophy. The sex, age, past ocular history, duration ofvision loss, and lens status were also reviewed for eachpatient.

The mean age of the patient was 65 years (range, 47–85years), 12 patients (52%) were women, and 15 eyes (65%)were phakic (Table 1). The duration of decreased visionranged from 1 month to 2 years. Follow-up varied from 3months to a year.

The median preoperative visual acuity was 20/100 witha range from 20/50 to counting fingers at 1 foot. Themedian postoperative visual acuity was 20/60 ranging from20/20 to 20/400. At the last recorded follow-up, 17patients (74%) had improved their visual acuity by at least2 chart lines. One patient had a lower visual acuitypostoperatively (20/100 preoperatively vs 20/200 postop-

TABLE 1. Clinical Parameters of Epiretinal Membrane Patients

Case Previous Surgery Preop VA Postop. VA

Follow-up

(Months)

Phakic vs

Pseudophakic

1 Scleral buckle 20/400 20/80 3 Phakic

2 Scleral buckle and VPP 20/300 20/200 12 Pseudophakic

3 CF 20/50 6 Phakic

4 Scleral buckle CF 20/200 12 Pseudophakic

5 20/60 20/40 3 Phakic

6 20/100 20/200 12 Phakic

7 20/300 20/30 9 Phakic

8 20/70 20/30 10 Pseudophakic

9 Scleral buckle 20/60 20/25 6 Phakic

10 20/70 20/70 3 Phakic

11 20/50 20/20 3 Pseudophakic

12 PPV 20/400 20/400 6 Phakic

13 PPV 20/200 20/100 5 Phakic

14 20/100 20/60 3 Pseudophakic

15 20/80 20/40 6 Phakic

16 Scleral buckle 20/70 20/30 7 Pseudophakic

17 PPV 20/300 20/80 8 Phakic

18 20/80 20/60 12 Pseudophakic

19 20/60 20/30 7 Phakic

20 Scleral buckle 20/300 20/40 8 Phakic

21 Scleral buckle 20/400 20/400 9 Phakic

22 20/60 20/60 12 Phakic

23 Scleral buckle 20/300 20/30 12 Pseudophakic

CF � Counting fingers; PPV � pars plana vitrectomy; VA � visual acuity.

AMERICAN JOURNAL OF OPHTHALMOLOGY910 JUNE 2003

eratively). No adverse reaction related to trypan blue wasobserved up to 1 year postsurgery.

The teratogenic and carcinogenic potential of trypanblue is well known.1,2 In these animal studies, it wasadministered via intraperitoneal injection in dosages vary-ing between 100 mg/kg and 300 mg/kg. For cataractsurgery, trypan blue is injected locally at a dose of approx-imately 0.005 mg/kg.

Peroperative use of trypan blue at a concentration of0.1% in anterior chamber surgery for the vital staining ofcorneal endothelium did not produce ocular complicationafter an 8-year follow-up.3 Trypan blue is also used tofacilitate capsulorhexis during phacoemulsification proce-dures in the absence of a red fundus reflex.4 To ourknowledge, no adverse effects have been reported.

No signs of toxicity were detected with light andelectron microscopy after continuous exposure of 0.06%trypan blue to the retina for 1 month in an in vivo rabbitmodel.5 Recently, trypan blue was also used successfully tostain epiretinal membranes during surgery for proliferativevitreoretinopathy.6 No adverse reactions were observed upto 3 months after surgery

In our study, 23 patients underwent epiretinal mem-brane peeling and, at the last recorded follow-up, 17 (74%)had improved visual acuity of at least 2 chart lines. Onepatient had a lower visual acuity postoperatively, which weattributed to the development of a 3 to 4� nuclearsclerosis postvitrectomy.

This study is by no means a thorough evaluation of theuse of trypan blue in vitreoretinal surgery and is merely anattempt to demonstrate its potential benefits. In our study,visualization and dissection of the epiretinal membranewas facilitated by trypan blue staining, and no signs oftoxicity or adverse reactions were noted after up to 1 yearof follow-up.

REFERENCES

1. Chung KT. The significance of azo-reduction in the mutagen-esis and carcinogenesis of azo dyes. Mutat Res 1983;114:269–281.

2. Schmidt KL, Milner K, Hilburn PJ, Schmidt WA. Ultrastruc-ture of trypan blue induced ocular defects: I. Retina and lens.Teratology 198;28:131–144.

3. Norn MS. Per operative trypan blue vital staining of cornealendothelium. Eight years’ follow up. Acta Ophthalmol 1980;58:550–555.

4. Melles GR, de Waard PW, Pameyer JH, Beekhuis HW.Trypan blue capsule staining to visualize the capsulorhexis incataract surgery. J Cataract Refract Surg 1990;25:7–9.

5. Veckeneer M, van Overdam K, Monzer J, et al. Oculartoxicity study of trypan blue injected into the vitreous cavityof rabbit eyes. Graefes Arch Clin Exp Ophthalmol 2001;239:698–704.

6. Feron E, Veckeneer M, Parys-Van Ginderdeuren R, et al.Trypan blue staining of epiretinal membranes in proliferativevitreoretinopathy. Arch Ophthalmol 2002;120:141–144.

Spontaneous Regression of ChoroidalMetastasis From Renal CellCarcinomaAmjad M. Hammad, MD,Gianmarco R. Paris, MD,Wichard A. J. van Heuven, MD,Ian M. Thompson, Jr., MD, andThomas D. Fitzsimmons, MD, MPH

PURPOSE: To describe a patient with choroidal metastasisfrom renal cell carcinoma that spontaneously regressedafter nephrectomy.DESIGN: Interventional case report.METHODS: A 48-year-old Hispanic woman presented withreduced vision in the left eye attributable to an elevatedchoroidal lesion and associated exudative retinal detach-ment. Oncology workup revealed a left kidney renal cellcarcinoma with pulmonary metastases. The patient un-derwent primary nephrectomy, without specific treat-ment of choroidal or pulmonary metastases.RESULTS: The metastatic choroidal lesion regressed andthe retinal detachment completely resolved, as evidencedby fundus photographs and ultrasonography.CONCLUSION: Choroidal metastasis from renal cell carci-noma may spontaneously regress after removal of theprimary tumor. (Am J Ophthalmol 2003;135:911–913.© 2003 by Elsevier Inc. All rights reserved.)

A 48-YEAR-OLD HISPANIC WOMAN PRESENTED TO THE

eye clinic with the chief complaint of blurred visionin the left eye. On examination, best-corrected visualacuity was 20/20 in the right eye and counting fingers at 3feet in the left eye with an afferent pupillary defect.Intraocular pressures, extraocular motility, confrontationfields, external exam, and slit lamp examination were allnormal. Funduscopic examination in the left eye (Figure 1,top) revealed a large, creamy lesion abutting the opticnerve and an adjacent exudative retinal detachment.Retinal vessels were congested and several hemorrhageswere present. By ultrasonography (Figure 1, bottom), thelesion measured 3.2 mm in elevation and 10 mm � 9 mmat base and was characterized by medium internal reflec-tivity, irregular internal structure, and marked vascularity.An oval, echogenic, low reflective lesion along the outerwall of the globe was also noted. Our working diagnosis

Accepted for publication Dec 16, 2002.From the Department of Ophthalmology (A.M.H., G.R.P.,

W.A.J.v.H., T.D.F.), and the Department of Urology (I.D.T.), Univer-sity of Texas Health Science Center at San Antonio, San Antonio,Texas.

Supported in part by an unrestricted grant from Research to PreventBlindness, Inc., New York, New York.

Inquiries to Wichard A.J. van Heuven, MD, Department of Ophthal-mology, University of Texas Health Sciences Center at San Antonio,7703 Floyd Curl Drive, San Antonio, TX 78229; fax: (210) 567-8413;e-mail: vanheuven@uthscsa.edu

BRIEF REPORTSVOL. 135, NO. 6 911