A South Australian ophthalmologist talks about why dyes are so important in his work and how one product, in particular, has taken safety in surgery to the next level.
In vitreoretinal surgery, where nearly every manoeuvre takes place millimetres from delicate retinal tissue, the margin for error is small. For Adelaide-based consultant vitreoretinal surgeon Dr Devaraj Supramaniam, that’s precisely why surgical dyes – and their safety profiles – prove their worth.
“In the posterior segment, most of what we operate on is transparent,” he says. “For years we relied on intuition, subtle reflections and experience.
“But dyes give us contrast, and contrast improves safety.”
Bausch + Lomb’s BLutein surgical dyes – BLutein DYE300 for vitreous staining and BLutein DYE500 for membranes such as the internal limiting membrane (ILM) and epiretinal membrane (ERM) – are now central to his approach.
The dyes use naturally sourced lutein, a pigment already found in the retina and known for its antioxidant and blue-light-filtering properties.
For Dr Supramaniam, the most significant factor is that these products are approved and tested for intraocular use, unlike many historical alternatives.
“One key differentiator is that the BLutein dyes have been thoroughly tested, have passed safety trials, and are approved for intraocular use,” he says.
“Over the years, we’ve often relied on alternative dyes, specifically for vitreous staining, that were used off-label. Moving to a dye such as the BLutein DYE300, that is approved and clinically evaluated for vitreous staining, is a significant step forward.
Working across public and private settings in Adelaide, Dr Supramaniam treats a broad range of complex retinal diseases.
“Commonly these patients present with visual distortion, trouble reading and difficulty with distance vision,” he says. “We’re often peeling a very thin, delicate membrane from the surface of the retina, by hand, under a microscope. It’s incredibly fine work.”
The BLutein dyes play different roles across the breadth of his surgical work.
The BLutein DYE300 vitreous dye suspends micronized orange lutein crystals within the vitreous humour, making an otherwise invisible structure visible.
“The lutein crystals are reflective,” he says.
“They disperse in the vitreous so you can actually see where it is. It allows you to do a more complete removal.”
Because the vitreous is generally adherent to the retina, removing it does risk causing traction and retinal tears.
“You can’t just aspirate it out. It’s like trying to yank sticky tape off paper – you’ll tear something. So staining it really does improve safety.”
The BLutein DYE500 membrane dye, by contrast, contains high-purity brilliant blue in a slightly different chemical composition called Pure Benzyl Brilliant Blue (PBB), which has strong affinity for collagen in ILM and ERM tissues with low retina distribution as shown in cell studies.1
“It stains vividly and with high affinity,” he says.
“So you don’t have to leave it in the eye for very long.”
And transmission across retinal membranes was the least with PBB as compared to other commonly used membrane dyes.1
“Lutein is something that’s intrinsic to the eye. So having it there – at least theoretically, could be beneficial – in terms of blue-light filtration and antioxidant effects.”
Bausch and Lomb also has an anterior capsule stain available, the BLutein DYE200, which is reimbursed on the Prescribed List.
Safer operations, better training
Dr Supramaniam trains vitreoretinal fellows in the public system. For him, dyes are essential teaching tools.
“It helps them visualise what’s happening and makes them safer surgeons,” he says.
“We’ve done this work for years without dyes, but like having a blind-spot monitor in your car – once it’s there, you realise how much safer it makes things.”
Experienced surgeons may feel they can manage without dyes, he says, but he sees a clear difference.
“You can compensate with skill and training, but the dyes definitely take safety to the next level.”
On the retinal surface, other dyes exist, but he has found the BLutein product performs particularly well.
“From what I’ve observed, the Bausch + Lomb BLutein 500 dye’s advantage is the enhanced contrast that one gets during membrane peeling and studies have alluded that this is possibly from its increased lipophilicity and high binding properties.”1
Despite being marginally costlier, Dr Supramaniam is unequivocal about their value. “Removal of the dye is quite efficient as well, with less swirling during aspiration”.
“For me, the safety and the improved surgical outcomes justify using them.”
When asked whether he would recommend them to other retinal surgeons, he was direct. “Yes, particularly the BLutein DYE300, because there’s really nothing else like it that’s approved,” he says. “It’s been a very useful addition to the vitreoretinal surgeon’s toolbox.”
References:
1. Spadaro A, et al; (2020) New Brilliant Blue G Derivative as Pharmacological Tool in Retinal Surgery. Front. Pharmacol. 11:708. doi: 10.3389/fphar.2020.00708.
