Severe retinal pigment epitheliopathy following brilliant blue G-assisted epiretinal membrane peeling

Chahveer Bindra; Parminder Bindra; Preeti Bindra

doi:10.4103/jcor.jcor_148_20

BRIEF COMMUNICATION

Year : 2021 | Volume : 9 | Issue : 2 | Page : 87-89

Severe retinal pigment epitheliopathy following brilliant blue G-assisted epiretinal membrane peeling

Chahveer Bindra, Parminder Bindra, Preeti Bindra
Department of Retina, Matashree Netralaya, Bhopal, Madhya Pradesh, India

Date of Submission	07-Aug-2020
Date of Decision	05-Apr-2021
Date of Acceptance	22-Apr-2021
Date of Web Publication	31-Jul-2021

Correspondence Address:
Chahveer Bindra
MS, E-4/158 Arera Colony, Bhopal - 462 016, Madhya Pradesh
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jcor.jcor_148_20

Abstract

To report a case of severe retinal pigment epitheliopathy following 23G pars plana vitrectomy and brilliant blue G (BBG) assisted epiretinal membrane (ERM) peeling in Stage IV primary ERM. Multimodal imaging analyses, including fundus photography, optical coherence tomography, and fundus autofluorescence, were performed to evaluate preoperative and postoperative findings. The patient underwent uneventful pars plana vitrectomy with BBG-assisted ERM peeling with the help of xenon endoilluminator and fine tipped forceps. Six weeks after surgery, the patient complained of paracentral scotomas. On evaluation with retinal imaging, pigmentary alteration was seen over the posterior pole corresponding to the peeled area. A risk of retinal pigment epitheliopathy after uneventful vitrectomy with BBG-assisted ERM peeling is present even with modern endoilluminators. The retinal phototoxicity, use of vital dyes, duration of surgery, stage of ERM preoperatively, and mechanical trauma during peeling may be associated risk factors.

Keywords: Brilliant blue G dye, epiretinal membrane peeling, mechanical trauma, phototoxicity, retinal pigment epitheliopathy

How to cite this article:
Bindra C, Bindra P, Bindra P. Severe retinal pigment epitheliopathy following brilliant blue G-assisted epiretinal membrane peeling. J Clin Ophthalmol Res 2021;9:87-9

How to cite this URL:
Bindra C, Bindra P, Bindra P. Severe retinal pigment epitheliopathy following brilliant blue G-assisted epiretinal membrane peeling. J Clin Ophthalmol Res [serial online] 2021 [cited 2023 Jun 2];9:87-9. Available from: https://www.jcor.in/text.asp?2021/9/2/87/322787

Epiretinal membrane (ERM) has been associated with a vast array of ocular conditions. ERM may cause disabling metamorphopsia and significantly reduced vision. Staining the membrane with brilliant blue G (BBG), indocyanine green (ICG), or trypan blue and peeling it during vitrectomy have greatly improved the rate of ERM removal.^[1] Various complications have been reported following peeling of membranes, including visual field defects, retinal tears and detachments, and retinal pigment epithelium (RPE) alterations of the posterior segment. These complications may be attributable to trauma due to internal limiting membrane (ILM) peeling, use of vital dyes, and phototoxicity. Studies have demonstrated toxic effects of vital dyes, especially ICG on retinal tissue.^[2] BBG has excellent postoperative results as compared to ICG and trypan blue dyes with minimal toxicity.^[3] This is case report of severe retinal pigment epitheliopathy following BBG-assisted membrane peeling.

Case Report

A 68-year-old woman presented with decreased vision in her left eye for the past 1 year along with metamorphopsia. On ocular examination, her best-corrected visual acuity was 20/20 in the right eye and 20/400 in the left eye. On evaluation, the patient had ERM in the left eye with dragging of vessels over macular area. On fluorescein angiography, no underlying vascular occlusion or pathology was seen in the left eye [Figure 1]. Spectral domain optical coherence tomography (SD-OCT) (Maestro, Topcon) revealed Stage IV ERM in the left eye with the absence of foveal pit, disrupted retinal layers, presence of ectopic inner foveal layers, and globally adhered ERM over macular area [Figure 2]. The patient underwent standard three-port pars plana vitrectomy using the Constellation system (Alcon/Grieshaber, USA). A core and peripheral vitrectomy was performed, and the induction of a complete posterior vitreous detachment was carried out by aspiration. The BBG (Ocublue Plus, 0.05% w/v, Aurolab) was injected through a cannula for a contact time of 2 min and then washed out in the fluid-filled eye. Peeling was completed with the help of xenon arc lamp endoilluminator (60% illumination) and fine-tipped forceps (Grieshaber ILM Forceps, Alcon) using the pinch-and-peel technique. After checking the peripheral retina, fluid–air and gas exchange (10% perfluoropropane gas) was done and scleral ports were closed with 6-0 vicryl sutures. Subconjunctival gentamicin was not used at the end of surgery. The total duration of surgery was 45 min. Six weeks after surgery, the patient's best-corrected visual acuity in the left eye improved to 20/180, with paracentral scotomas. On evaluation on fundus photography, macular area was free from ERM, but pigmentation was seen over the posterior pole corresponding to peeled area. Postoperative SD-OCT revealed the absence of ERM with indistinct foveal contour, hyperreflective deposits over the outer retina and RPE, and intermittent disruption of external limiting membrane with back scattering [Figure 3]. On fundus autofluorescence (TRC-NW8F Plus, Topcon), stippled area of hypo and hyperfluorescence was observed corresponding to peeled area. The central foveal area was spared of the pigmentary changes [Figure 4].

Figure 1: Fundus photograph and fluorescein angiograph of the right eye showing normal fundus with no retinal pigment epithelium changes or dystrophy (a and c). Preoperative fundus photograph and fluorescein angiograph of the left eye shows Stage IV epiretinal membrane with dragging of the retinal vessels over macular area with no underlying pathology (b and d)

Click here to view

Figure 2: Horizontal (a) and vertical (b) scans of spectral domain optical coherence tomography at baseline showing absence of foveal pit, disrupted retinal layers, presence of ectopic inner foveal layers, and globally adhered epiretinal membrane over macular area

Click here to view

Figure 3: Horizontal (a) and vertical (b) scans of spectral domain optical coherence tomography taken 6 weeks after surgery showing the absence of epiretinal membrane and puckering with indistinct foveal contour, hyperreflective deposits over the outer retina and retinal pigment epithelium, and intermittent disruption of external limiting membrane with back scattering

Click here to view

Figure 4: Color fundus photography (a) in the postoperative visit showing altered pigmentation over the posterior pole corresponding to the peeled area. Fundus autofluorescence imaging (b) showing stippled area of hypo and hyperfluorescence. The central foveal area was spared of the pigmentary changes

Click here to view

Discussion

The procedure involved uneventful surgery with pars plana vitrectomy and BBG-assisted ERM removal. Several cases have been reported on maculopathy following macular hole surgery.^[4],[5] Our case highlights the occurrence of retinal pigment epitheliopathy following BBG-assisted ERM peeling in Stage IV ERM. The retinal pigment epithelial cells and photoreceptors were primarily involved along with sparing of inner retinal layers. RPE degeneration may occur due to mechanical trauma to Muller cells, phototoxicity, and vital dye-induced toxicity. Direct mechanical trauma may occur during the creation of initial flap of membrane, but it is usually limited to the site of contact. Further, there may be damage to Muller cell foot plate secondary to peeling. Phototoxic maculopathy has been described by several reports and is associated with increased surgical time, prior fundus pigmentation, increased exposure to light, and less distance between endoilluminator and retina.^[6] In our case, the surgical time was slightly prolonged (45 min), with standard procedure technique and no prior fundus pigmentation. Intraoperative light exposure causes phototoxic damage RPE that could be enhanced by vital dyes by photosensitization, especially ICG.^[7] A slim possibility of phototoxicity similar to ICG has been described for BBG.^[3] Extensive RPE damage along with choroidal thinning has been reported following the use of BBG dye-assisted macular hole surgery.^[5],[8] In our case, retinal pigment epitheliopathy was seen corresponding to peeled area which may be due to phototoxicity enhanced by BBG dye. Since the peeled area was only affected, there is high probability that the integrity of ILM acts as a barrier for photosensitization of RPE by vital dyes. Of note, in Stage IV ERM, mechanical trauma to Muller cell is much higher due to increased adhesion between the Muller cells and both ILM and ERM.^[9] Thus, there is increased risk of retinal damage after ERM and ILM peeling increasing the intraretinal penetration of BBG molecules, which in turn produces phototoxic radicles. Relative sparing of the fovea was seen in our case which may be attributed to protective effect of increased xanthophyll in the foveal area as has been reported in earlier study.^[10]

To conclude, there is a risk of retinal pigment epitheliopathy after BBG-assisted ERM peeling even with modern endoilluminators. The retinal phototoxicity, use of vital dyes, duration of surgery, stage of ERM preoperatively, and mechanical trauma during peeling may be associated risk factors which need further study. Patients complaining with paracentral scotomas postoperatively should be assessed for retinal pigment epitheliopathy with appropriate imaging.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Al-Halafi AM. Chromovitrectomy: Update. Saudi J Ophthalmol 2013;27:271-6.
2.	Gandorfer A, Haritoglou C, Kampik A. Toxicity of indocyanine green in vitreoretinal surgery. Dev Ophthalmol 2008;42:69-81.
3.	Hernández F, Alpizar-Alvarez N, Wu L. Chromovitrectomy: An update. J Ophthalmic Vis Res 2014;9:251-9.
4.	Jindal A, Pathengay A, Mithal K, Chhablani J, Pappuru RR, Flynn HW. Macular toxicity following brilliant blue G-assisted macular hole surgery-A report of three cases. Nepal J Ophthalmol 2014;6:98-101.
5.	Singh SR, Chhablani J. Geographic atrophy with choroidal thinning following brilliant blue staining. BMJ Case Rep 2019;12:e2300242.
6.	Charles S. Illumination and phototoxicity issues in vitreoretinal surgery. Retina 2008;28:1-4.
7.	Balaiya S, Koushan K, McLauchlan T, Chalam KV. Assessment of the effect of distance and duration of illumination on retinal pigment epithelial cells exposed to varying doses of brilliant blue green. J Ocul Pharmacol Ther 2014;30:625-33.
8.	Venkatesh R, Aseem A, Jain K, Yadav NK. Combined brilliant blue G and xenon light induced outer retinal layer damage following macular hole surgery. Indian J Ophthalmol 2020;68:247-9. [PUBMED] [Full text]
9.	Romano MR, Ilardi G, Ferrara M, Cennamo G, Parolini B, Mariotti C, et al. Macular peeling-induced retinal damage: Clinical and histopathological evaluation after using different dyes. Graefes Arch Clin Exp Ophthalmol 2018;256:1573-80.
10.	Kweon EY, Ahn M, Lee DW, You IC, Kim MJ, Cho NC. Operating microscope light-induced phototoxic maculopathy after transscleral sutured posterior chamber intraocular lens implantation. Retina 2009;29:1491-5.