I read the article by Marques and coauthors1 with great interest. I have not used indocyanine green because in Canada, trypan blue has been available under the tradename Vision Blue since November 1999. Trypan blue for capsule staining was first described at meetings in 1998 by its inventor, Gerrit Melles, MD. After Vision Blue was licensed in July 1999, it was released, almost simultaneously, in Canada and the United States in November 1999. However, it was withdrawn from the U.S. market 3 months later when it was reclassified as a drug, requiring more extensive U.S. Food and Drug Administration submissions for reapproval, which has not yet occurred.
In November 1999, I became the first Canadian ophthalmologist to use Vision Blue in variations of my evolving ultimate soft-shell technique (USST) (S.A. Arshinoff, MD, “The Ultimate Soft Shell Technique for Viscoadaptives,” presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, San Diego, California, USA, April 2001). As the initial developer of Healon5 (sodium hyaluronate 2.3%), a project I began with Lars Skoglund of Pharmacia in September 1996, I was eager to incorporate Vision Blue into my evolving USST to make surgery of white cataracts easier.2 My initial presentations of the USST with Vision Blue and an article I wrote on the it2 describe a technique using only 2 steps in which Vision Blue is substituted for balanced salt solution (BSS). I have presented this technique and shown video clips of it at numerous meetings. Since then, I have found, as did Marques and coauthors, that a 3-step technique yields a clearer view of the capsule; however, I do not perform this in the same manner as the authors.
The authors may find the technique is more effective when Vision Blue is used in a 3-step variation of the USST as follows: Fill the anterior chamber 80% to 90% with a viscoadaptive ophthalmic viscosurgical device (OVD), being careful not to inject initially at the wound, which would blockade the incision. Paint trypan blue over the capsule, using a tiny drop ejected onto the capsule surface through a 27-gauge, hockey-stick cannula attached to a tuberculin syringe containing trypan blue (Figure 1). Paint the dye over the capsule surface using the distal “blade” of the hockey stick. Slowly inject BSS under the viscoadaptive OVD onto the capsule surface using a 10 cc syringe and a similar 27-gauge, hockey-stick cannula. Slow injection will not move the overlying OVD layer and will wash out excess trypan blue. Next, suddenly increase the injection speed to a “pulse,” injected away from the wound, with the cannula aperture positioned on the capsule surface near the pupil margin and distal from the incision, in the style of the USST. This will force the OVD upward and backward to blockade the incision and pressurize the eye. Figure 2 shows a capsulorhexis performed with this technique; the view of the capsule is crystal clear, greatly facilitating capsulorhexis. One can see how much clearer the view is in the photographs shown here than in photographs of Marques and coauthors.
The authors correctly discovered that modifying the USST to incorporate trypan blue yields excellent results, but I suggest that if they reverse the order of the trypan blue and BSS injections as described above, the results will be better.
Steve Arshinoff MD, FRCSC
Toronto, Ontario, Canada
1. Marques DMV, Marques FF, Osher RH. Three-step technique for staining the anterior lens capsule with indocyanine green or trypan blue. J Cataract Refract Surg 2004; 30:13-16
2. Arshinoff SA. Using BSS with viscoadaptives in the ultimate soft-shell technique. J Cataract Refract Surg 2002; 28:1509-1514