Purpose: To report on the combined use of trypan blue (TB) and brilliant blue G (BBG) for staining the epiretinal membrane (ERM) and internal limiting membrane (ILM) during vitrectomy and to describe the histopathological findings. Methods: 10 surgical specimens were removed from 10 eyes with macular pucker during vitrectomy using a commercially available combination of TB and BBG for ERM and ILM staining and peeling. Specimens were evaluated using light and transmission electron microscopy. Results: In all cases the combination of TB and BBG was useful for identifying and delineating ERM and ILM. No complications related to the use of the dye were observed during or after surgery. Glial cells were present in all specimens. Hyalocytes were observed in 6 cases and myofibroblasts in 3 of them. In 7 cases native vitreous collagen fibrils were found on the ILM, while in 5 specimens newly formed collagen was present. No clinical evidence of toxicity was observed during the 3-month follow-up. Conclusion: The combined use of TB and BBG appeared to be very useful intraoperatively to improve the visualization of ERM and ILM, thus facilitating their complete removal. Anatomical and histopathological findings demonstrated the safety and the efficacy of this vital dye.

Mitchell P, Smith W, Chey T, Wang JJ, Chang A: Prevalence and associations of epiretinal membranes. The Blue Mountains Eye Study, Australia. Ophthalmology 1997; 104: 1033–1040.
Stevenson W, Prospero Ponce CM, Agarwal DR, Gelman R, Christoforidis JB: Epiretinal membrane: optical coherence tomography-based diagnosis and classification. Clin Ophthalmol 2016; 10: 527–534.
Kampik A: Pathology of epiretinal membrane, idiopathic macular hole, and vitreomacular traction syndrome. Retina 2012; 32: 194–198.
Miyazaki M, Nakamura H, Kubo M, Kiyohara Y, Iida M, Ishibashi T, Nose Y: Prevalence and risk factors for epiretinal membranes in a Japanese population: the Hisayama Study. Graefes Arch Clin Exp Ophthalmol 2003; 241: 642–646.
Treumer F, Wacker N, Junge O, Hedderich J, Roider J, Hillenkamp J: Foveal structure and thickness of retinal layers long-term after surgical peeling of idiopathic epiretinal membrane. Invest Ophthalmol Vis Sci 2011; 52: 744–750.
Bovey EH, Uffer S, Achache F: Surgery for epimacular membrane: impact of retinal internal limiting membrane removal on functional outcome. Retina 2004; 24: 728–735.
Machemer R: The development of pars plana vitrectomy: a personal account. Graefes Arch Clin Exp Ophthalmol 1995; 233: 453–468.
Kwok AK, Lai TY, Yuen KS: Epiretinal membrane surgery with or without internal limiting membrane peeling. Clin Exp Ophthalmol 2005; 33: 379–385.
Schechet SA, DeVience E, Thompson JT: The effect of internal limiting membrane peeling on idiopathic epiretinal membrane surgery, with a review of the literature. Retina 2017; 37: 873–880.
Donati G, Kapetanios AD, Pournaras CJ: Complications of surgery for epiretinal membranes. Graefes Arch Clin Exp Ophthalmol 1998; 236: 739–746.
Margherio RR, Cox MS Jr, Trese MS, Murphy PL, Johnson J, Minor LA: Removal of epiretinal membranes. Ophthalmology 1985; 92: 1075–1083.
Wilkinson CP: Recurrent macular pucker. Am J Ophthalmol 1979; 88: 1029–1031.
Sandali O, El Sanharawi M, Basli E, Bonnel S, Lecuen N, Barale PO, Borderie V, Laroche L, Monin C: Epiretinal membrane recurrence: incidence, characteristics, evolution, and preventive and risk factors. Retina 2013; 33: 2032–2038.
Tognetto D, di Lauro MT, Fanni D, Zagidullina A, Michelone L, Ravalico G: Iatrogenic retinal traumas in ophthalmic surgery. Graefes Arch Clin Exp Ophthalmol 2008; 246: 1361–1372.
Feron EJ, Veckeneer M, Parys-Van Ginderdeuren R, Van Lommel A, Melles GR, Stalmans P: Trypan blue staining of internal limiting membranes in proliferative vitreoretinopaty. Arch Ophthalmol 2002; 120: 141–144.
Teba FA, Mohr A, Eckardt C, Wong D, Kusaka S, Joondeph BC, Feron EJ, Stalmans P, Melles GR: Trypan blue staining in vitreomacular surgery. Ophthalmology 2003; 110: 2409–2412.
Burk SE, Da Mata AP, Snyder ME, Rosa RH Jr, Foster RE: Indocyanine green-assisted peeling of the internal limiting membrane. Ophthalmology 2000; 107: 2010–2014.
Da Mata AP, Burk SE, Riemann CD, Rosa RH Jr, Snyder ME, Petersen MR, Foster RE: Indocyanine green-assisted peeling of the retinal internal limiting membrane during vitrectomy surgery for macular hole repair. Ophthalmology 2001; 108: 1187–1192.
Wollensak G: Biomechanical changes of internal limiting membrane after indocyanine green staining. Dev Ophthalmol 2008; 42: 82–90.
Veckeneer M, van Overdam K, Monzer J, Kobuch K, van Marle W, Spekreijse H, van Meurs J: Ocular toxicity study of trypan blue injected into the vitreous cavity of rabbit eyes. Graefes Arch Clin Exp Ophthalmol 2001; 239: 698–704.
Gandorfer A, Messmer EM, Ulbig MW, Kampik A: Indocyanine green selectively stains the internal limiting membrane. Am J Ophthalmol 2001; 131: 387–388.
Gandorfer A, Haritoglou C, Gass CA, Ulbig MW, Kampik A: Indocyanine green-assisted peeling of the internal limiting membrane may cause retinal damage. Am J Ophthalmol 2001; 132: 431–433.
Engelbrecht NE, Freeman J, Sternberg P Jr, Aaberg TM Sr, Aaberg TM Jr, Martin DF, Sippy BD: Retinal pigment epithelial changes after macular hole surgery with indocyanine green-assisted internal limiting membrane peeling. Am J Ophthalmol 2002; 133: 89–94.
Weinberger AW, Kirchhof B, Mazinani BE, Schrage NF: Persistent indocyanine green (ICG) fluorescence 6 weeks after intraocular ICG administration for macular hole surgery. Graefes Arch Clin Exp Ophthalmol 2001; 239: 388–390.
Sippy BD, Engelbrecht NE, Hubbard GB, Moriarty SE, Jiang S, Aaberg TM Jr, Aaberg TM Sr, Grossniklaus HE, Sternberg P Jr: Indocyanine green affected on cultured human retinal pigment epithelial cells: implication for macular hole surgery. Am J Ophthalmol 2001; 132: 433–435.
Balaiya S, Brar VS, Murthy RK, Chalam KV: Comparative in vitro safety analysis of dye for chromovitrectomy: indocyanine green, brilliant blue green, bromophenol blue, and infracyanine green. Retina 2011; 31: 1128–1136.
Ooi YL, Khang TF, Naidu M, Fong KCS: The structural effect of intravitreal brilliant blue G and indocyanine green in rats eyes. Eye 2013; 27,425–431.
Enaida H, Hisatomi T, Goto Y, Hata Y, Ueno A, Miura M, Kubota T, Ishibashi T: Preclinical investigation of internal limiting membrane staining and peeling using intravitreal brilliant blue G. Retina 2006; 26: 623–630.
Penha FM, Pons M, Costa EF, Rodrigues EB, Maia M, Marin-Castaño ME, Farah ME: Effect of vital dyes on retinal pigmented epithelial cell viability and apoptosis: implications for chromovitrectomy. Ophthalmologica 2013; 230: 41–50.
Mansoor S, Sharma A, Cáceres-del-Carpio J, Zacharias LC, Patil AJ, Gupta N, Limb GA, Kenney MC, Kuppermann BD: Effects of light on retinal pigment epithelial cells, neurosensory retinal cells and Müller cells treated with brilliant blue G. Clin Exp Ophthalmol 2015; 43: 820–829.
Veckeneer M, Mohr A, Alharthi E, Azad R, Bashshur ZF, Bertelli E, Bejjani RA, Bouassida B, Bourla D, Crespo IC, Fahed C, Fayyad F, Mura M, Nawrocki J, Rivett K, Scharioth GB, Shkvorchenko DO, Szurman P, Van Wijck H, Wong IY, Wong DS, Frank J, Oellerich S, Bruinsma M, Melles GR: Novel “heavy” dye for retinal membrane staining during macular surgery: multicenter clinical assessment. Acta Ophthalmol 2014; 92: 339–344.
Januschowski K, Mueller S, Spitzer MS, Hoffmann J, Schramm C, Schultheiss M, Bartz-Schmidt KU, Szurman P: Investigating the biocompatibility of two new heavy dyes for vitreoretinal surgery with an isolated perfused vertebrate retina organ culture model and a retinal ganglion cell line. Graefes Arch Clin Exp Ophthalmol 2012; 250: 533–545.
Sebag J: Anomalous posterior vitreous detachment: a unifying concept in vitreo-retinal disease. Graefes Arch Clin Exp Ophthalmol 2004; 242: 690–698.
Sebag J: Vitreoschisis. Graefes Arch Clin Exp Ophthalmol 2008; 246: 329–332.
Schumann RG, Gandorfer A, Ziada J, Scheler R, Schaumberger MM, Wolf A, Kampik A, Haritoglou C: Hyalocytes in idiopathic epiretinal membranes: a correlative light and electron microscopic study. Graefes Arch Clin Exp Ophthalmol 2014; 254: 1887–1895.
Schumann RG, Gandorfer A, Priglinger SG, Kampik A, Haritoglou C: Vital dyes for macular surgery. A comparative electron microscopy study of the internal limiting membrane. Retina 2009; 29: 669–676.
Kampik A, Kenyon KR, Michels RG, Green WR, de la Cruz ZC: Epiretinal and vitreous membranes. Comparative study of 56 cases. Arch Ophthalmol 1981; 99: 1445–1454.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.