OSLI Retina

October 2018

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788 Ophthalmic Surgery, Lasers & Imaging Retina | Healio.com/OSLIRetina ■ S U R G I C A L R E V I E W ■ Vital Dyes in Vitreomacular Surgery Peter Bracha, MD; Thomas A. Ciulla, MD; Caroline R. Baumal, MD ABSTRACT: Vital dyes contain complex molecules with chromophores that stain living tissues and have greatly enhanced identification and removal of transparent vitreoretinal tissues during surgery. Several "chromovitrectomy" dyes are frequently used by vitreoretinal specialists, including indo- cyanine green, trypan blue, brilliant blue G, and triamcinolone acetonide; other dyes are also un- der investigation. Trypan Blue was approved by the U.S. Food and Drug Administration (FDA) for epiretinal membrane removal, and preservative- free triamcinolone acetonide was approved by the FDA for intraocular use. However, currently avail- able chromovitrectomy dyes have their limitations, and of particular concern for some of them is the possibility for acute and chronic toxicity to the neu- rosensory retina and retinal pigmented epithelium. The potentially irreversible acute toxicity and oth- er limitations, such as lack of long-term safety pro- files, highlight the need for further advancements. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:788-798.] INTRODUCTION In all surgical fields, visualization of tissues and anatomic planes assumes paramount importance. In vitreoretinal surgery, the surgical planes may be only microns thick, and neighboring nerve fiber layer tis- sues are susceptible to mechanical damage with sec- ondary adverse visual sequelae. Thus, surgical dis- section in the appropriate plane without traumatizing underlying retinal structures is critical. Particularly challenging in retinal surgery is the visualization of transparent preretinal tissues such as internal limit- ing membrane (ILM), epiretinal membrane (ERM), and the vitreous cortex. Vital dyes are complex mol- ecules containing chromophores, the structure of a molecule responsible color, 1 that stain living tissues and have greatly enhanced identification and removal of transparent anatomical layers during vitreoretinal surgery. Currently available chromovitrectomy dyes do have their limitations. The properties of an ideal dye for vitreoretinal surgery include lack of toxicity to all retinal layers, easy application and extraction from the eye, excellent staining and contrast of desired tis- sues, no potential for phototoxicity, low cost, minimal preparation, and existing U.S. Food and Drug Admin- istration (FDA) approval. Several chromovitrectomy dyes are frequently used by vitreoretinal specialists, including indocyanine green (ICG), trypan blue (TB), From the Scheie Eye Institute, University of Pennsylvania, Philadelphia, and previously from the Department of Ophthalmology, Indiana University School of Medicine, Indianapolis (PB); Retina Service, Midwest Eye Institute, Indianapolis (TAC); and Tufts University School of Medicine, New England Eye Center, Boston (CRB). Originally submitted February 4, 2018. Revision received July 8, 2018. Accepted for publication September 9, 2018. Dr. Bracha reports no relevant financial disclosures. Dr. Ciulla has an employment relationship with Spark Therapeutics; however, this manuscript was writ- ten during his work as a Volunteer Clinical Professor of Ophthalmology at Indiana University School of Medicine, and none of the work herein represents any official position or opinion of Spark Therapeutics or its management. Dr. Baumal has served as a consultant for Stealth Biotherapeutics, on the advi- sory board for Genentech, as as a speaker for Optovue and Zeiss outside the submitted work. Address correspondence to Peter Bracha, MD, Scheie Eye Institute, 51 N 39th Street, Philadelphia, PA, 19104; email: peterbracha@yahoo.com. doi: 10.3928/23258160-20181002-07

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