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(A) Fundus autofluorescence showing diffuse RPE mottling in the macula and mid-periphery at three-weeks follow-up. (B) Further progression and coalescence of the RPE disturbances is observed at three and (C) six-months follow-up. (D) At one-year follow-up, hypoautofluorescent areas corresponding to RPE atrophy are noted.
Source publication
Purpose
To describe a case of diffuse retinal pigment epithelium (RPE) disturbance following 23-gauge pars plana vitrectomy (PPV) with the inverted internal limiting membrane (ILM) technique and Brilliant Blue staining for a high myopic macular hole (MH).
Observations
A 53-year-old pseudophakic high myopic female was referred to the Vitreoretinal...
Contexts in source publication
Context 1
... on examination (Fig. 2a). OCT showed severe disruption of the external retinal layers, as well as extensive areas of RPE migration and thickening ( Fig. 1c and d). Fundus autofluorescence (FAF) showed diffuse areas of both hypo-and hyperautofluorescence involving the macular and peripapillary areas and extending to the upper midperiphery ( Fig. 3a). Progression and coalescence of the distinct areas of RPE atrophy was observed on consecutive follow-up visits ( Fig. 3b and c). There was no history of unusual exposure to sunlight or UVA/ UVB radiation sources, and she was not taking any systemic medications at the ...
Context 2
... RPE migration and thickening ( Fig. 1c and d). Fundus autofluorescence (FAF) showed diffuse areas of both hypo-and hyperautofluorescence involving the macular and peripapillary areas and extending to the upper midperiphery ( Fig. 3a). Progression and coalescence of the distinct areas of RPE atrophy was observed on consecutive follow-up visits ( Fig. 3b and c). There was no history of unusual exposure to sunlight or UVA/ UVB radiation sources, and she was not taking any systemic medications at the ...
Context 3
... one-year follow-up visit, visual acuity remained 20/400, and further progression of the atrophy was observed extending further into the periphery (Fig. 2b). FAF showed large hypoautofluorescent areas corresponding to RPE atrophy and photoreceptor loss (Fig. ...
Context 4
... weeks after PPV, our patient developed diffuse RPE mottling in the macula and mid periphery which progressed and coalesced over the next weeks (Fig. 3a-c). Exposure of the RPE to the BBG was limited to the macular hole, and even though jet stream induced subretinal migration of the dye in absence of a tear or hole has been reported, this was not observed during the surgical procedure. 4 In this case, the repeated staining of the ILM staining could pose a potential risk for retinal ...
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Background
The purpose is to report the second case, to our knowledge, of suspected paclitaxel-induced phototoxic maculopathy following pars plana vitrectomy surgery.
Case presentation
63-year-old phakic female who underwent an uneventful phaco-vitrectomy to treat a complete macular hole, developing macular phototoxicity in the post-operatively pe...
Bilateral solar phototoxicity caused macular hole in one eye of a sun-worshipper. Surgery improved the vision beyond the fellow eye.
Background: The purpose of this study was to look at the long-term effects of retinal phototoxicity after macular hole repair surgery using xenon endolight illumination and Brilliant blue G (BBG) dye.
Case presentation: An elderly man in his late seventies underwent para plana vitrectomy with BBG dye to repair an idiopathic full-thickness macular h...
Citations
... Moreover, starting at the 6-and 12-months follow-up, 71% of eyes developed RPE subfoveal atrophy, which was detectable in infrared OCT scans and in fundus photography, as a white roundish lesion with well-defined borders in the foveal area slowly enlarging during the study period. Previous reports in literature highlighted the occurrence of RPE atrophy after MH surgery but addressed this complication to the use of vital dyes, such as trypan blue and indocyanine green [27,28], and, more recently, Brilliant blue [29]. Nevertheless, all these case showed a diffuse RPE atrophy involving larger areas or the entire posterior pole. ...
Background
The aim of this study is to evaluate long-term anatomical and functional outcomes of autologous internal limiting membrane (ILM) transplantation in refractory highly myopic macular holes (HMMHs).
Methods
Retrospective interventional analysis of 13 eyes with refractory HMMH undergoing autologous ILM transplantation with gas tamponade. Best-corrected visual acuity (BCVA, Snellen), optical coherence tomography and fundus photography were scheduled at baseline and every follow-up visit (1, 3, 6, 12, 18, 24 months and the most recent). Preoperatively, we collected minimum linear diameter (MLD) and basal diameter (BD). Post-operatively, rates of external limiting membrane (ELM)/ellipsoid zone (EZ) restoration, excessive gliosis and subfoveal retinal pigmented epithelium (RPE) atrophy were evaluated.
Results
Average AXL was 31.45 ± 2.07 mm and mean follow-up was 47.2 ± 31.4 months. Anatomical success was reached in 7/13 eyes (54%), while 2 cases showed persisting HMMH, 2 cases had early recurrence and 2 cases late recurrence. BCVA went from 0.19 ± 0.18 to 0.22 ± 0.20 at final follow-up (p = 0.64), improving in 5/13 eyes (38%). One eye showed continuous ELM and EZ lines, while another eye showed an irregular ELM but no EZ. Post-operatively, 5 eyes (71%) developed progressive atrophy of the subfoveal RPE, while excessive gliosis was reported in 3 eyes (43%). Furthermore, one patient developed post-operative chronic macular edema-like changes in the perifoveal area.
Conclusion
Autologous ILM transplantation showed controversial anatomical outcomes and and poor visual results in refractory HMMH. Moreover, progressive subfoveal patchy atrophy and excessive gliosis are possible post-operative complications.
... The induced maculopathy described is suspected to be a consequence of a phototoxicity injury produced during endo-illumination due to previous photosensitization of the retina by the previous use of paclitaxel. Although phototoxicity secondary to Brilliant Blue G (BBG) staining during vitrectomy has been previously reported in cases with a prolonged endo-illumination time, this could not be the case, as surgical time was significantly shorter compared with the cases reported in the published series and Membrane Blue Dual dye, containing 0.025% BBG only, was the dye used in this surgery [11][12][13]. In the absence of an alternative explanation, paclitaxel phototoxic maculopathy was considered as a plausible cause. ...
Background
The purpose is to report the second case, to our knowledge, of suspected paclitaxel-induced phototoxic maculopathy following pars plana vitrectomy surgery.
Case presentation
63-year-old phakic female who underwent an uneventful phaco-vitrectomy to treat a complete macular hole, developing macular phototoxicity in the post-operatively period that could not be explained by the surgery itself and could only be attributed to a possible photosensitization induced by the previous use of paclitaxel.
Conclusions
The use of paclitaxel has been widely extended as a chemotherapy drug to treat breast cancer. It works by altering the intracellular microtubular reorganization and, based on this mechanism of action, photosensitivity has been previously described. We report a case of suspected paclitaxel-induced macular phototoxicity following ocular endoillumination during vitrectomy surgery.
... For example, BBG was reported to be either safe or harmful depending on the concentration, duration of contact, concurrent exposure to light, and kind of solvent used [13,16,[31][32][33][34]. Moreover, when using dyes during chromovitrectomy in humans, cytotoxic effects might be also be enhanced by direct light exposure, leading to severe RPE damage with a permanent decrease in visual function [35,36]. ...
Although recent data highlight the greater protective effects exerted by Membrane Blue Dual (MBD), a precise analysis of the mechanisms of action is missing. We examined the effects of MBD with/without polyethylene glycol (PEG) on both human retinal pigment epithelial cells (ARPE-19) and retinal ganglion cells-like (RGC-5) cultured in the presence/absence of ultraviolet B (UVB) treatment on mitochondria function, oxidants, and apoptosis. In ARPE-19/RGC-5 cells either treated or not with UVB, the effects of MBD with/without PEG were evaluated by specific assays for viability, mitochondrial membrane potential and mitochondrial reactive oxygen species (mitoROS) release. Annexin V was used to detect apoptosis, whereas trypan blue and the scratch assay were used for proliferation/migration. In both physiologic conditions and in the presence of UVB, MBD with/without PEG increased cell viability, mitochondrial membrane potential, proliferation and migration in both ARPE-19 and RGC-5 cells. In general, the effects of MBD with PEG were greater than those caused by MBD without PEG. Our results suggest that, in particular, MBD with PEG is a safe and effective dye for vitreoretinal surgery through the modulation of mitochondrial function.
... Nevertheless, as reported by Donati et al. [3] and as in one of our cases, it may be present in patients in whom dyes were not used since membranes were accurately visualized without the need for staining. In 2021, Ortiz et al. [12] presented a case of RPE atrophy following PPV assisted by BB in a high myopic MH. Inoue et al. [6], Uamoto et al. [7] and Engelbrecht [13] reported some cases associated with ICG use. ...
... Mechanical damage is probably the reason in our cases, due to the important adherence between membranes and retina, chiefly in the second case. Also, intraoperative retinal phototoxicity from the microscope and the endoilluminator must be considered as potential cause of RPE atrophy [12]. ...
Objective: To describe the development of retinal pigment epithelium (RPE) atrophy after uncomplicated pars plana vitrectomy (PPV) with epiretinal membrane (ERM) and/or internal limiting membrane (ILM) peeling in 2 patients.
Cases description:
Case 1: A 79-years-old female with diagnosis of a full-thickness macular hole in her right eye (OD) with best corrected visual acuity (BCVA) of: 20/100 and left eye (OS): 20/70. After surgery she developed large RPE hyperplasia and presented hand movement that did not improve with pinhole.
Case 2: A 69-years-old female patient who had ERM in her OS with BCVA of 20/30 in both eyes (OU). PPV was assisted with brilliant blue (BB) to better visualize the ILM. During follow-up visits we evidenced RPE atrophy in the zone where peeling was done. In the last control after 2-years, her visual acuity was 20/40 that did not improve with pinhole.
Discussion: There are three possible mechanisms to explain this complication: toxic damage, mechanical trauma during the membrane removal with forceps, or a combination of both. In our cases, a combination of them is probably the cause of the presence of RPE atrophy.
Conclusion: Vitrectomy with membrane removal is successful in most cases with low rate of complications. Because RPE atrophy is infrequent, our suggestion is to continue performing this technique and if possible, it should be done without dye staining to minimize risks.
Abbreviations: ERM = epiretinal membrane, ILM = internal limiting membrane, MH = macular hole, RPE = Retinal pigment epithelium, OD = right eye, BCVA = Best corrected visual acuity, OS = left eye, OU = both eyes, IOL = intraocular lens, OCT = Optical coherence tomography, BB = Brilliant blue, TB = Trypan blue, ICG = indocyanine green
... Although phototoxicity secondary to Brilliant Blue G (BBG) staining during vitrectomy has been previously reported, typically following prolonged endoillumination, it was considered unlikely in this patient as compared to previous suspected cases of BBG phototoxicity surgical time was significantly shorter and Membrane Blue Dual dye containing only 0.025% BBG was used. [10][11][12] In the absence of an alternative explanation, paclitaxel phototoxic maculopathy was considered the most likely cause as paclitaxel is known to induce maculopathy and the inferior distribution of maculopathy corresponded with the endoillumination probe entering superiorly. [4][5][6][7][8][9] Paclitaxel belongs to the taxane class of chemotherapy drugs which act by disrupting intracellular microtubular reorganization. ...
Purpose
To report the first case, to our knowledge, of suspected paclitaxel induced phototoxic maculopathy following vitrectomy surgery.
Observations
A 62-year-old phakic female receiving paclitaxel therapy for ovarian carcinoma presented with a best corrected visual acuity (BCVA) of 20/40 OD with an epiretinal membrane (ERM) and lamellar macular hole on spectral domain optical coherence tomography (SD-OCT). The patient underwent an uneventful pars plana vitrectomy with ERM peel using standard illumination and vitrectomy settings. Membrane Blue Dual (DORC, Netherlands) was used to stain the ERM. Two weeks post-operatively, the patient presented with a reduced BCVA of 20/200 in the operated eye. Fluorescein and indocyanine green angiography revealed right sided patchy hypofluorescence and hyperfluorescence secondary to retinal pigment epithelium changes with intact choroidal and retinal vasculature. SD-OCT and fundoscopy showed right sided loss of ellipsoid layer, increased reflectivity within the retinal pigmented epithelium and subretinal fibrosis without cystoid macular edema. Four months post-operatively her vision had stabilized to 20/160; unfortunately, the patient was palliated a month later due to ovarian carcinoma progression.
Conclusions
and Importance: A number of drugs are known to increase photosensitivity to solar and artificial forms of radiation. Paclitaxel use has been widely reported to cause dermatological photosensitivity. We report a case of suspected paclitaxel induced phototoxic maculopathy following endoillumination during vitrectomy surgery.
Purpose:
The aim of this study is to describe the clinical and multimodal imaging findings in patients with macular atrophy following macular hole surgery assisted by Membrane Blue Dual.
Method:
This study is a monocenter, retrospective, observational case series that included patients who presented macular atrophy following macular hole surgery.
Results:
Among the patients included in this study, four were operated for idiopathic macular hole and one for total retinal detachment associated with macular hole. In all patients the internal limiting membrane was brittle and adherent and multiple stains were required. One month postoperatively all patients showed a reduced visual acuity excepted the patient with total retinal detachment. At fundus examination all patients showed patchy atrophy with a mottled hypo- and hyperpigmented appearance in the macular region. Optical coherence tomography scans demonstrated a closed macular hole with retinal thinning, disruption of the external retinal layers and irregular retinal pigment epithelium thickening. Fundus autofluorescence showed a well-defined area of both hypo- and hyper-autofluorescence involving the macular area.
Conclusions:
Macular atrophy following Membrane Blue Dual assisted internal limiting membrane peeling represents a severe complication that vitreoretinal surgeons should be aware of and that should be taken into account in preoperative evaluation and surgical procedure planning. In order to reduce the risk of this complication, we recommend to ensure the best conditions of visibility, to reduce as much as possible the intensity and the distance of the endoillumination from the retina, and to use as little dye as possible.
