Progressive atrophy of retinal pigment epithelium after trypan-blue-assisted ILM peeling for macular hole surgery

Abstract

We report a case of progressive atrophy of the retinal pigment epithelium (RPE) after trypan-blue-assisted peeling of internal limiting membrane (ILM) for macular hole surgery. A 68-year-old Caucasian female underwent a 20-g pars plana vitrectomy for a chronic stage-3 macular hole. The ILM was stained with 0.06% trypan blue (VisionBlue™, DORC Netherlands) for 2 min after fluid air exchange. Dye was reapplied for another 2 min due to poor staining. The ILM was completely removed around the macular hole with forceps. RPE atrophy was noticed at the edge of the hole 1 month after surgery. It progressively increased in intensity and enlarged over 2 years. Her final visual acuity was counting fingers, significantly worse compared to her presenting visual acuity of 20/200. Progressive atrophy of RPE in our patient was most likely due to the toxicity of trypan blue. Reapplication of the dye may increase the likelihood of toxicity.

Figure 1

(a) Stage-3 macular hole measuring 680 μ in diameter. (b) Midphase fluorescein angiogram of the left eye at presentation showing mild hyperfluorescence at the base of the hole

Figure 2

One month post-op: RPE atrophy seen as a ring-shaped area of hypopigmentation corresponding to the edge of the macular hole

Figure 3

(a) Seven months post-op: Atrophy of the RPE has extended to include the entire base and edge of the macular hole. (b) Spectral domain OCT at 7 months showing closed macular hole, interruption of inner segment/outer segment junction, and RPE atrophy

Figure 4

Two years post-op: (a) Area of RPE atrophy has become more intense and increased in size to 790 μin diameter. (b) Spectral domain OCT showing a closed macular hole, defect in inner segment/ outer segment junction, further attenuation of outer retinal layers compared to Figure 3B, and increased transmission of light, consistent with atrophy of the RPE