Use of Trypan Blue Before Descemetorhexis in Endothelial Surgeries

Descemet membrane without endothelial keratoplasty (DWEK) or Descemet stripping only is an alternative to the Descemet membrane endothelial keratoplasty (DMEK) in Fuchs endothelial dystrophy, where peripheral endothelial cell density is above 1000 cells/mm².¹ Trypan blue is a vital dye that helps assess the health of corneal endothelium by staining the areas of dead endothelial cells.²

Figure 1A and B show the clinical image and optical coherence tomography of the right eye of a 45–year-old with corneal endothelial dystrophy. Intraoperatively, 0.06% of trypan blue (Auroblue, Aurolab, Madurai, India) was injected in the anterior chamber before performing descemetorhexis. The trypan blue dye was washed out using balanced salt solution after 40 seconds of duration. The area of endothelial cell loss was highlighted intraoperatively (Fig. 1C). In view of the large area of endothelial cell loss (area stained in blue), which was apparent under the operating microscope after injecting trypan blue in the anterior chamber, the patient underwent phacoemulsification with DMEK.

Figure 1: A, Slitlamp photograph showing edema and secondary subepithelial changes in the central cornea in an eye with endothelial dystrophy. B, Optical coherence tomography showing increased central pachymetry (692 microns) and epithelial changes. C, Digital photographs intraoperatively showing the staining pattern on endothelial surface corresponding to the area of endothelial cell loss.

The staining characteristics of the recipient bed using trypan blue before descemetorhexis has 2 main surgical implications.

First, the extent of staining of the recipient bed serves as an intraoperative criterion for choosing between the DWEK and DMEK procedures. Secondly, it would help determine the size of descemetorhexis in DWEK/descemet stripping only by demarcating the area of endothelial loss, which cannot be clinically visualized unless stained with the trypan blue dye.