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Dye aids visualization in enucleation

Staining the capsule with trypan blue during enucleation may decrease complications.

ByKatrina Altersitz

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Trypan blue can be used to avoid complications during enucleation by helping the surgeon differentiate between the anterior Tenon’s capsule and the conjunctiva during closure, said Minas T. Coroneo, FRANZCO, MD, FRACS, MS, and colleagues.

“It can be difficult to distinguish accurately the anterior Tenon capsule from the conjunctiva,” they wrote in Archives of Ophthalmology. “To our knowledge, this technique is the first extraocular application of trypan blue.”

In order to decrease the risk of exposure after enucleation, surgeons perform closure of the posterior Tenon’s capsule, anterior Tenon’s capsule and conjunctiva, Dr. Coroneo and colleagues said. The homogeneity of Tenon’s capsule and the conjunctiva makes it difficult to distinguish between the two.

The researchers injected Vision Blue (trypan blue, Dutch Ophthalmic Research Center) into the existing wound with a syringe and irrigated the wound with normal saline.

“The Tenon capsule stained clearly with no uptake of trypan blue by the conjunctiva, allowing visualization of the Tenon capsule separate from the conjunctiva during layered closure,” they said.

In achieving this distinction, they had visual confirmation that there was “no entrapment of the conjunctiva in the Tenon capsule wound” and that “there was complete closure of the conjunctiva over the Tenon capsule.”

Complications

If the conjunctiva is accidentally inverted during closure of Tenon’s capsule, conjunctival cysts can form, the authors noted.

The incidence of cysts ranges from 0.3% to 8%, and they can cause infection or prostheses to be ill-fitting or hard to retain, the researchers said, citing other studies.

The cysts also could be avoided by identifying and closing Tenon’s capsule and the conjunctiva separately, they added.

“Although the incidence of conjunctival cysts following enucleation appears low,” they said, “we feel that our technique is a worthwhile preventative measure given the possible severe complications of conjunctival cysts.”

The researchers said that the complete separation of Tenon’s capsule and conjunctiva might also reduce other complications such as implant exposure or extrusion.

“The use of trypan blue also provides an excellent means by which trainee surgeons can be certain that in enucleation surgery closure of the wound occurs in separate layers,” they said.

For more information:

• Minas T. Coroneo, FRANZCO, MD, FRACS, MS, can be reached at Department of Ophthalmology, University of New South Wales at Prince of Wales Hospital, High Street, Randwick, New South Wales 2031, Australia; e-mail: m.coroneo@unsw.edu.au. Dr. Coroneo holds patents covering the ocular use of trypan blue and has a licensing agreement with DORC International.

• DORC International, manufacturer of Vision Blue, can be reached at +31-181-458-080; fax: +31-181-458-090; Web site: www.dorc.nl.

Reference:

• Cheung LM, Wilcsek GA, Francis IC, Coroneo MT. Staining of the tenon capsule with trypan blue during enucleation surgery. Arch Ophthalmol. 2005;123:1125-1126.

• Katrina Altersitz is an OSN Staff Writer who covers all aspects of ophthalmology.