Expert presents case of trypan blue migration into vitreous cavity during phaco
Key takeaways:
- Trypan blue unexpectedly migrated into the vitreous cavity during cataract surgery.
- The zonules were likely damaged by sport-related repeated micro-trauma.
ATHENS, Greece — Sport-related repeated micro-trauma could be the cause of traumatic cataract and zonular damage without clinically evident signs, according to a presenter.
At the ESCRS winter meeting, Dimitrios Tsouris, MD, of Greece presented an unexpected case of trypan blue migration in the vitreous cavity during phacoemulsification in a 30-year-old man with cataract in his left eye.
“It was a normal, fine-looking cataract,” he said. “The trypan blue was instilled under air and exchanged with [balanced salt solution]. But after that, everything turned blue, and the surgeon realized that the trypan blue had migrated in the anterior vitreous cavity.”
Tsouris was assisting the operating surgeon, and following the initial surprise, they faced the dilemma of what to do next and why this had happened. Because the patient asked for immediate visual rehabilitation and they were concerned about the possible toxicity of prolonged exposure to trypan blue on the retinal pigment epithelium, the decision was made to perform 25-gauge partial vitrectomy. A toric IOL was implanted, and the patient achieved a satisfactory functional outcome with no further problems. OCT in the follow-up visits did not show any abnormalities.
To find out why this happened, Tsouris and his colleague conducted a literature search and found that trypan blue can migrate to the posterior segment in eyes with pseudoexfoliation, in eyes with previous surgery or laser peripheral iridotomy, in cases of uveitis cataract, or when hooks are used to lift the iris. But none of these applied to their case. They also found that the migration can happen in routine cases when there is a forceful exchange of trypan blue with an ophthalmic viscosurgical device, but the dye had been exchanged with balanced salt solution.
“Why did we have this happen without any obvious risk factor?” Tsouris said.
Cataract at the age of 30 years is unusual. By examining the patient’s history, Tsouris observed that the patient was a semiprofessional football player.
“Football is the single most common sport associated with ocular trauma, even more dangerous than boxing,” he said.
The mechanism by which football can cause trauma to the ocular structures is either by direct impact on the eye, which allows a small knuckle of the football to enter the orbit and deform the globe, or by repeated micro-concussions caused by frequent headers.
“Overall, I think that we were encountered with a traumatic cataract,” he said.
By looking more closely at the images acquired before surgery, the typical rosette, stellate-shaped opacification of traumatic cataract was visible. Although there were not clinically evident signs of zonule dialysis, the trypan blue had migrated into the vitreous cavity through damaged zonules.
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Tsouris D. Trypan blue migration in the vitreous during phacoemulsification. Presented at: ESCRS winter meeting; Feb. 28-March 2, 2025; Athens, Greece.
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