The removal of the ILM during vitreoretinal surgery has become a standard of care, especially in macular hole surgery. Also, many surgeons use vital stains to counterstain the ILM when trying to identify epiretinal membrane tissue. While the vast majority of US retina specialists had used ICG in the past in an off-label manner, concerns around ocular toxicity, lack of a continuous supply, and the need for mixing the drug before use have been reasons why other dyes are a need.
Brilliant Blue has been used in Europe and Asia for years with good efficacy and safety record. Tissue Blue (Brilliant Blue G ophthalmic solution by DORC) was recently approved by the FDA for staining the ILM. It comes as a premixed solution to remove the variable of incorrectly mixing which could have occurred with ICG. Below are links to two cases in which I used Brilliant blue for the first time.
My initial impressions? Tissue Blue did a very nice job staining the ILM in the setting of a macular hole without significant epiretinal membrane tissue. When counterstaining for the ERM, it was less than adequate at identifying the peripheral ILM tissue to begin the peel. The solution comes pre-mixed which increases the ability to open quickly for a case but lacks the 5% dextrose that would be typically in ICG so it does not sit as well on the fovea. To get the correct amount of stain of the ILM, I’ve increased my staining period to 1 min from the typical 30 seconds I’ve used for ICG in the past. And from a cost perspective its near equivalent to ICG at our institution. Would love to hear your perspectives on this new product.