Visual rehabilitation in eyes with cataract and coexisting corneal opacity can be best performed by a corneal triple procedure (combined penetrating keratoplasty with cataract surgery). However, factors like graft rejection and infection may jeopardize the outcome of penetrating keratoplasty. This may be of special relevance in developing countries like India, where there is a long waiting period for keratoplasty because of paucity of good-quality donor material. Moreover, the consequences of graft failure can be grave in one-eyed individuals who have lost vision in the other eye due to an irreversible ocular pathology. In these patients, particularly if the corneal opacity is vascularized, cataract extraction with intraocular lens implantation may provide a suboptimal but long-term vision. However, cataract extraction is difficult in these eyes because of poor visibility through the corneal opacity.

We used trypan blue dye to stain the anterior capsule to enhance visualization during surgery. Trypan blue is commonly used to stain the anterior capsule in order to enhance visualization for capsulorhexis in white cataracts.1, 2 This dye has been considered safe for intraoperative use as it has been used clinically to examine endothelial cell damage after cataract extraction3 and is also used to examine endothelium of donor corneoscleral button before corneal transplantation.4 In eyes with cataract and coexisting corneal opacities, trypan blue has been used successfully to enhance visualization to perform phacoemulsification.5

We performed manual non-phaco small incision cataract surgery (SICS) in 12 eyes of 12 patients with cataract and coexisting corneal opacity using 0.1% trypan blue dye and evaluated the outcome. All these patients were one eyed and had corneal opacity with deep stromal vascularization, thereby having a high risk of graft rejection and failure. The aim of performing this procedure was to provide ambulatory vision to these patients and to defer corneal triple procedure as long as possible.

In all, 12 eyes of 12 patients with significant cataract and corneal opacity, which was only partly covering the visual axis, were selected. Surgery was performed under peribulbar anesthesia. A small peritomy was performed superiorly and a 6 mm frown-shaped scleral groove was made, which was then tunnelled by crescent knife and the anterior chamber was entered by a 3.2 mm angled keratome. Trypan blue 0.1% (Vision Blue, Dorc International, The Netherlands) was injected under air bubble over the anterior capsule and then washed with balanced salt solution after 15 s and viscoelastic was injected. A large continuous curvilinear capsulorhexis of approximately 6.0 mm was made and hydrodissection and hydrodelineation were performed. Nucleus was prolapsed and delivered by irrigating vectis and cortical matter aspirated by simcoe cannula. A single piece intraocular lens (IOL) of polymethylmethacrylate of 6.5 mm optic size was implanted into the capsular bag. The anterior chamber was reformed from the side port with balanced salt solution. No suture was placed for wound closure.

Postoperatively, patients were prescribed topical betamethasone sodium phosphate 0.1% and ciprofloxacin 0.3% q.i.d. each for 4 weeks and tropicamide 1% t.i.d. for 1 week. Patients were followed up on day 1, 1 week, and 6 weeks. On the postoperative day 1, there was no residual staining of the anterior capsule and all eyes showed a quiet anterior chamber with normal intraocular pressure.

The best corrected visual acuity (BCVA) was ≤3/60 preoperatively in all the eyes and at 6 weeks postoperatively, this improved to ≥6/36 in all the eyes of which four eyes had BCVA of ≥6/18.

In the present study, we observed that the dye improved visualization of the anterior capsule and a complete capsulorhexis could be performed successfully in all the eyes. The anterior capsule could be seen throughout the surgical procedure. In all the eyes, the procedure could be performed successfully and without any complication.

Patients with nebulomacular corneal opacities and a visually debilitating cataract may become ambulatory with cataract surgery alone. To bring about a faster visual rehabilitation, cataract extraction is performed these days through a small incision and is preferred over the conventional extracapsular extraction. Among the small incision surgeries, the choice can be between phacoemulsification and manual nonphaco small incision cataract surgery. In a similar study, phacoemulsification has been performed in such eyes using trypan blue dye.5 However, we felt that the risk of complications is higher in phaco than in nonphaco small incision surgery. This is especially relevant in these eyes as it is difficult to manage complications like posterior capsular tear and nucleus/IOL drop in eyes with corneal opacity.

Although the visual outcome in these cases was less than optimal, all patients had enough vision to enable them to carry out their daily activities. Trypan blue-assisted SICS in cases of corneal opacities with cataract is safe and feasible, both in terms of faster visual rehabilitation and minimal risk of complications.