Surgical Dyes and Triamcinolone in Eye Surgery: Trypan Blue, ICG, Brilliant Blue and How to Prepare Them
Last updated: November 2026
Dyes make transparent tissues visible: the anterior capsule in a white cataract, the epiretinal membrane (ERM) and internal limiting membrane (ILM) during vitrectomy, and vitreous after a capsule rupture. Each dye has its own concentration, preparation and toxicity profile.
Which dye stains what
| Agent | Usual concentration | Stains | Key points |
|---|---|---|---|
| Trypan blue (e.g. VisionBlue) | 0.06% | Anterior capsule | Inject under air or under OVD, wait a few seconds, wash out; use in white, mature or brunescent cataracts and poor red reflex |
| Trypan blue (e.g. MembraneBlue) | 0.15% | ERM (weakly ILM) | Apply after fluid-air exchange, or mixed 3:1 with 10% glucose to sink without exchange |
| Brilliant blue G (e.g. ILM-Blue, TissueBlue) | 0.025% | ILM (selective) | Iso-osmolar; generally considered safer than ICG |
| Indocyanine green (ICG) | Diluted to under 0.5 mg/mL | ILM (stains and stiffens it) | Dissolve first in sterile water (saline can precipitate it), then dilute with BSS to avoid a hypo-osmolar solution; minimise contact time and light exposure |
| Infracyanine green | Under 0.5 mg/mL | ILM | No iodide; dissolves in glucose, not water |
| Triamcinolone acetonide | 40 mg/mL; 0.1–0.3 mL | Vitreous and posterior hyaloid (crystals) | Prefer preservative-free (Triesence); Kenalog contains benzyl alcohol |
| Fluorescein | Low concentration | Vitreous | Off-label; less effective than triamcinolone |
Trypan blue for capsulorhexis
Technique
- Make the side port and main incision; fill the chamber with air (or a thin layer of dispersive OVD).
- Inject a small amount of 0.06% trypan blue over the anterior capsule.
- Wait about 10–30 seconds, then wash out with BSS.
- Fill with OVD and perform the capsulorhexis.
Do not inject behind the iris or into the vitreous: in eyes with a weak posterior capsule or zonules, trypan blue can stain the vitreous and spoil the red reflex. It can also stain hydrophilic IOLs if left in the eye.
ICG and brilliant blue for ILM peeling
- Most surgeons now prefer brilliant blue G for ILM peeling because ICG has been linked to retinal pigment epithelium changes and visual field defects at higher concentrations or with long exposure and strong light.
- If ICG is used: dissolve the powder in sterile water, dilute with BSS to under 0.5 mg/mL, use the smallest volume, wash out within seconds, and lower the light pipe intensity.
- Avoid dye going under the retina through a macular hole: some surgeons put a drop of viscoelastic or blood over the hole first.
Triamcinolone
- Why: crystals stick to vitreous and the posterior hyaloid, showing residual vitreous during vitrectomy or in the anterior chamber after posterior capsule rupture.
- Which product: preservative-free triamcinolone is preferred. Preserved suspensions such as Kenalog/Kenacort contain benzyl alcohol; some surgeons wash it (let it settle, remove the supernatant, resuspend in BSS) or filter it, but these methods are not standardised. Sterile endophthalmitis-like reactions have been reported.
- Never use methylprednisolone acetate (Depo-Medrol) inside the eye: its preservative is highly toxic to the retina.
- Side effects: raised IOP and cataract progression with retained crystals.
All dyes must be sterile, preservative-free, iso-osmolar and pH-balanced. Check the label for intraocular use, and never improvise with dyes or steroids meant for other routes.
Pearls
- Inject trypan blue under air for even capsule staining with less dye.
- Brilliant blue G is the usual first choice for ILM; if using ICG, keep it dilute and brief.
- For vitreous in the AC after a capsule tear, a little preservative-free triamcinolone shows exactly what to cut.
Common mistakes
- Dissolving ICG directly in saline (precipitates) or leaving it hypo-osmolar.
- Using Depo-Medrol inside the eye.
- Letting trypan blue reach the vitreous in a weak-zonule eye.
Test yourself: flip cards
Quick quiz
Related: Intracameral Drugs in Cataract Surgery: Moxifloxacin, Cefuroxime, Adrenaline, Lignocaine and Mydrane, With Dilution Safety, Phacoemulsification Step by Step: A Beginner's Guide, Retina, IOL Injectors and Cartridges for Residents: Alcon A, B, C, D, Preloaded Systems, J&J Unfolder, Zeiss, Medicel and Indian Lenses, Intravitreal Injection Protocol: Asepsis, Technique and Complications.
Key sources
- EyeWiki (AAO). Chromovitrectomy
- Retina Today. Chromovitrectomy: a primer (2023)
- Rodrigues EB, et al. Vital dyes for chromovitrectomy. Curr Opin Ophthalmol. 2007;18:179-187
- Melles GR, et al. Trypan blue capsule staining to visualize the capsulorhexis in cataract surgery. J Cataract Refract Surg. 1999;25:7-9
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