- Email: [email protected]
DS
CASE REPORT
Intraocular lens staining associated with Prosed/DS Lance S. Ferguson, MD
A 59-year-old pseudophakic woman with a history of Prosed/DS use demonstrated a discolored Tecnis Z9001 (AMO) silicone intraocular lens (IOL). Polymethyl methacrylate (PMMA), hydrophobic acrylic, silicone, and Collamer IOLs were submerged in a physiologic concentration of methylene blue at 35 C for 8 weeks and evaluated. No staining was noted in PMMA or hydrophobic acrylic IOLs, variable staining was noted in silicone IOLs, and intense staining was noted in Collamer IOLs. This is the first report of IOL staining with systemic use of methylene blue and of Collamer lens staining characteristics. J Cataract Refract Surg 2008; 34:334–336 Q 2008 ASCRS and ESCRS
Systemic use of rifamycins has been reported as the likely cause of intraocular lens (IOL) discoloration in vivo.1 Staining of acrylic hydrophilic IOLs has been reported with intraoperative use of trypan blue2, inadvertent intraoperative use of methylene blue3, postoperative fluorescein angiography4, and in vitro staining with fluorescein, indocyanine green, and trypan blue.5 Recently, IOL staining was noted in a patient treated with Prosed/DS (Star Pharmaceuticals, Inc.), an oral medication for chronic cystitis. Prosed/DS contains methenamine, phenyl salicylate, benzoic acid, atropine sulfate, hyoscyamine sulfate, and methylene blue. In the United States, it is sold under many trade names: Atrosept, Dolsed, Hexalol, Trac Tab 2X, UAA, Uridon Modified, Urimed, Urinary Antiseptic No. 2, Urised, Uriseptic, Uritab, Uritin, and Uro-Ves. CASE REPORT A 59-year-old woman complaining of suboptimal vision and haze after cataract surgery performed 4 months previously sought a second opinion before having cataract surgery in the fellow eye. A laser treatment for diabetic maculopathy had been performed before an uneventful cataract surgery, a phacoemulsification procedure performed without the use of a capsular dye. A Tecnis (AMO) Z9001 silicone IOL
had been implanted. Postoperatively, 2 YAG capsulotomies were performed, but there was no improvement in vision. The patient’s medical history was noteworthy for diabetes mellitus and chronic cystitis, for which she was treated with Prosed/DS. She also reported use of multiple supplements, including cranberry, cherry, and blueberry extracts. Ophthalmic examination showed a best corrected visual acuity of 20/25 2 in the pseudophakic eye. Color plate testing was normal. Slitlamp evaluation revealed a cabernet tint to the IOL (Figures 1 and 2), which was noteworthy for multiple laser pits. The capsulotomy was centered, and the posterior pole evaluation revealed punctate chorioretinal scarring immediately temporal to the macula. Prosed/DS was suspect as one of the components is methylene blue. To determine whether Prosed/DS might be a cause of the staining, a solution was prepared assuming 100% absorption, no protein binding, and homogenous distribution. Because the extracellular fluid volume in a 60 kg woman is approximately 12 liters and the Prosed/DS dose is 2 tablets, the solution was created by dissolving one-half tablet in 3 liters of sterile normal saline. Polymethyl methacrylate (PMMA), hydrophobic acrylic, silicone, and Collamer IOLs were submerged and incubated at 35 C for 8 weeks. There was no staining in the PMMA and hydrophobic acrylic IOLs, variable staining in the silicone IOLs models, and intense staining in the hydrophilic Collamer IOL (Figures 3 to 9). A similar solution was prepared with the reported dose of cranberry extract. There was no IOL staining after incubation of an identical period and temperature. Solutions of the other extracts were not studied.
Accepted for publication September 23, 2007. From Commonwealth Eye Surgery, Lexington, Kentucky, USA. The author has no financial or proprietary interest in any material or method mentioned. Corresponding author: Lance S. Ferguson, MD, Commonwealth Eye Surgery, 2353 Alexandria Drive, Suite 350, Lexington, Kentucky 40504, USA. E-mail: [email protected].
334
Q 2008 ASCRS and ESCRS Published by Elsevier Inc.
DISCUSSION The patient’s complaint of ‘‘haze’’ may have been associated with the staining of the IOL, but the cause is difficult to ascertain given the macular scarring associated with the preoperative laser treatment. She did not note any change in tint between the operated eye and the cataractous fellow eye. Similarly, individuals 0886-3350/07/$dsee front matter doi:10.1016/j.jcrs.2007.09.020
335
CASE REPORT: IOL STAINING WITH PROSED/DS
Figure 1. Slitlamp image (undilated) of stained Tecnis Z9001 silicone IOL.
Figure 3. Alcon AcrySof SN60WF acrylic IOL.
Figure 2. Slitlamp image (dilated) of stained Tecnis Z9001 silicone IOL.
Figure 4. Alcon AcrySof MA60AC acrylic IOL.
Figure 5. Alcon CZ70BD PMMA IOL.
Figure 6. Bausch & Lomb LI61SE silicone IOL.
Figure 7. Staar AQ2010V silicone IOL.
implanted with the yellow-tinted acrylic IOLs may not perceive a color shift when a fellow eye is implanted with a clear IOL. However, when the density of the staining is more pronounced, as in the case of intraoperative use of trypan blue in conjunction with a hydrophilic acrylic IOL, the patient described visual symptoms as being ‘‘dark.’’2 Although Bisol et al.6 report a case of a stained hydrophilic IOL in which the patient remained asymptomatic, there may be
a greater risk for reaching the symptomatic threshold with the indefinite use of systemic medications. With known use of systemic rifamycins and medications containing methylene blue, a safer approach might include selecting a PMMA or hydrophobic acrylic IOL. If silicone or hydrophilic acrylic IOLs are used, the patient should be given information about the future use of rifamycins or medications that contain methylene blue.
J CATARACT REFRACT SURG - VOL 34, FEBRUARY 2008
336
CASE REPORT: IOL STAINING WITH PROSED/DS
there have been no in vivo reports of Collamer staining; perhaps the fibronectin coat associated with these IOLs inhibits staining. However, until further study, it is prudent to provide this information, particularly to younger refractive surgical patients who receive a Collamer phakic IOL. REFERENCES 1. Jones DF, Irwin AE. Discoloration of intraocular lens subsequent to rifabutin use. Arch Ophthalmol 2002; 120:1211–1212 2. Werner L, Apple DJ, Crema AS, et al. Permanent blue discoloration of a hydrogel intraocular lens by intraoperative trypan blue. J Cataract Refract Surg 2002; 28:1279–1286 3. Stevens S, Werner L, Mamalis N. Corneal edema and permanent blue discoloration of a silicone intraocular lens by methylene blue. Ophthalmic Surg Lasers Imaging 2007; 38:136–141 4. Grewal SPS, Jain R, Grewal D, Gupta R. In vivo fluorescein staining of SI-30NB silicone intraocular lens. J Cataract Refract Surg 2007; 33:156–158 5. Ozbek Z, Saatci AO, Durak I, et al. Staining of intraocular lenses with various dyes: a study of digital image analysis. Ophthalmologica 2004; 218:243–247 6. Bisol T, Rezenda RA, Guedes J, Dantas AM. Effect of blue staining of expandable hydrophilic intraocular lenses on contrast sensitivity and glare vision. J Cataract Refract Surg 2004; 30:1732–1735
Figure 8. Tecnis Z9001 silicone IOL.
Figure 9. Staar CQ2015V Collamer IOL.
The intense staining noted in Collamer IOLs suggests that a warning about the peri-operative or future use of medications in the rifamycin group or those with methylene blue may be appropriate, as well as a surgical caveat to thoroughly wash out the anterior chamber after using trypan blue. To my knowledge,
First author: Lance S. Ferguson, MD Commonwealth Eye Surgery Lexington, Kentucky, USA
J CATARACT REFRACT SURG - VOL 34, FEBRUARY 2008
Intraocular lens staining associated with Prosed/DS Lance S. Ferguson, MD
A 59-year-old pseudophakic woman with a history of Prosed/DS use demonstrated a discolored Tecnis Z9001 (AMO) silicone intraocular lens (IOL). Polymethyl methacrylate (PMMA), hydrophobic acrylic, silicone, and Collamer IOLs were submerged in a physiologic concentration of methylene blue at 35 C for 8 weeks and evaluated. No staining was noted in PMMA or hydrophobic acrylic IOLs, variable staining was noted in silicone IOLs, and intense staining was noted in Collamer IOLs. This is the first report of IOL staining with systemic use of methylene blue and of Collamer lens staining characteristics. J Cataract Refract Surg 2008; 34:334–336 Q 2008 ASCRS and ESCRS
Systemic use of rifamycins has been reported as the likely cause of intraocular lens (IOL) discoloration in vivo.1 Staining of acrylic hydrophilic IOLs has been reported with intraoperative use of trypan blue2, inadvertent intraoperative use of methylene blue3, postoperative fluorescein angiography4, and in vitro staining with fluorescein, indocyanine green, and trypan blue.5 Recently, IOL staining was noted in a patient treated with Prosed/DS (Star Pharmaceuticals, Inc.), an oral medication for chronic cystitis. Prosed/DS contains methenamine, phenyl salicylate, benzoic acid, atropine sulfate, hyoscyamine sulfate, and methylene blue. In the United States, it is sold under many trade names: Atrosept, Dolsed, Hexalol, Trac Tab 2X, UAA, Uridon Modified, Urimed, Urinary Antiseptic No. 2, Urised, Uriseptic, Uritab, Uritin, and Uro-Ves. CASE REPORT A 59-year-old woman complaining of suboptimal vision and haze after cataract surgery performed 4 months previously sought a second opinion before having cataract surgery in the fellow eye. A laser treatment for diabetic maculopathy had been performed before an uneventful cataract surgery, a phacoemulsification procedure performed without the use of a capsular dye. A Tecnis (AMO) Z9001 silicone IOL
had been implanted. Postoperatively, 2 YAG capsulotomies were performed, but there was no improvement in vision. The patient’s medical history was noteworthy for diabetes mellitus and chronic cystitis, for which she was treated with Prosed/DS. She also reported use of multiple supplements, including cranberry, cherry, and blueberry extracts. Ophthalmic examination showed a best corrected visual acuity of 20/25 2 in the pseudophakic eye. Color plate testing was normal. Slitlamp evaluation revealed a cabernet tint to the IOL (Figures 1 and 2), which was noteworthy for multiple laser pits. The capsulotomy was centered, and the posterior pole evaluation revealed punctate chorioretinal scarring immediately temporal to the macula. Prosed/DS was suspect as one of the components is methylene blue. To determine whether Prosed/DS might be a cause of the staining, a solution was prepared assuming 100% absorption, no protein binding, and homogenous distribution. Because the extracellular fluid volume in a 60 kg woman is approximately 12 liters and the Prosed/DS dose is 2 tablets, the solution was created by dissolving one-half tablet in 3 liters of sterile normal saline. Polymethyl methacrylate (PMMA), hydrophobic acrylic, silicone, and Collamer IOLs were submerged and incubated at 35 C for 8 weeks. There was no staining in the PMMA and hydrophobic acrylic IOLs, variable staining in the silicone IOLs models, and intense staining in the hydrophilic Collamer IOL (Figures 3 to 9). A similar solution was prepared with the reported dose of cranberry extract. There was no IOL staining after incubation of an identical period and temperature. Solutions of the other extracts were not studied.
Accepted for publication September 23, 2007. From Commonwealth Eye Surgery, Lexington, Kentucky, USA. The author has no financial or proprietary interest in any material or method mentioned. Corresponding author: Lance S. Ferguson, MD, Commonwealth Eye Surgery, 2353 Alexandria Drive, Suite 350, Lexington, Kentucky 40504, USA. E-mail: [email protected].
334
Q 2008 ASCRS and ESCRS Published by Elsevier Inc.
DISCUSSION The patient’s complaint of ‘‘haze’’ may have been associated with the staining of the IOL, but the cause is difficult to ascertain given the macular scarring associated with the preoperative laser treatment. She did not note any change in tint between the operated eye and the cataractous fellow eye. Similarly, individuals 0886-3350/07/$dsee front matter doi:10.1016/j.jcrs.2007.09.020
335
CASE REPORT: IOL STAINING WITH PROSED/DS
Figure 1. Slitlamp image (undilated) of stained Tecnis Z9001 silicone IOL.
Figure 3. Alcon AcrySof SN60WF acrylic IOL.
Figure 2. Slitlamp image (dilated) of stained Tecnis Z9001 silicone IOL.
Figure 4. Alcon AcrySof MA60AC acrylic IOL.
Figure 5. Alcon CZ70BD PMMA IOL.
Figure 6. Bausch & Lomb LI61SE silicone IOL.
Figure 7. Staar AQ2010V silicone IOL.
implanted with the yellow-tinted acrylic IOLs may not perceive a color shift when a fellow eye is implanted with a clear IOL. However, when the density of the staining is more pronounced, as in the case of intraoperative use of trypan blue in conjunction with a hydrophilic acrylic IOL, the patient described visual symptoms as being ‘‘dark.’’2 Although Bisol et al.6 report a case of a stained hydrophilic IOL in which the patient remained asymptomatic, there may be
a greater risk for reaching the symptomatic threshold with the indefinite use of systemic medications. With known use of systemic rifamycins and medications containing methylene blue, a safer approach might include selecting a PMMA or hydrophobic acrylic IOL. If silicone or hydrophilic acrylic IOLs are used, the patient should be given information about the future use of rifamycins or medications that contain methylene blue.
J CATARACT REFRACT SURG - VOL 34, FEBRUARY 2008
336
CASE REPORT: IOL STAINING WITH PROSED/DS
there have been no in vivo reports of Collamer staining; perhaps the fibronectin coat associated with these IOLs inhibits staining. However, until further study, it is prudent to provide this information, particularly to younger refractive surgical patients who receive a Collamer phakic IOL. REFERENCES 1. Jones DF, Irwin AE. Discoloration of intraocular lens subsequent to rifabutin use. Arch Ophthalmol 2002; 120:1211–1212 2. Werner L, Apple DJ, Crema AS, et al. Permanent blue discoloration of a hydrogel intraocular lens by intraoperative trypan blue. J Cataract Refract Surg 2002; 28:1279–1286 3. Stevens S, Werner L, Mamalis N. Corneal edema and permanent blue discoloration of a silicone intraocular lens by methylene blue. Ophthalmic Surg Lasers Imaging 2007; 38:136–141 4. Grewal SPS, Jain R, Grewal D, Gupta R. In vivo fluorescein staining of SI-30NB silicone intraocular lens. J Cataract Refract Surg 2007; 33:156–158 5. Ozbek Z, Saatci AO, Durak I, et al. Staining of intraocular lenses with various dyes: a study of digital image analysis. Ophthalmologica 2004; 218:243–247 6. Bisol T, Rezenda RA, Guedes J, Dantas AM. Effect of blue staining of expandable hydrophilic intraocular lenses on contrast sensitivity and glare vision. J Cataract Refract Surg 2004; 30:1732–1735
Figure 8. Tecnis Z9001 silicone IOL.
Figure 9. Staar CQ2015V Collamer IOL.
The intense staining noted in Collamer IOLs suggests that a warning about the peri-operative or future use of medications in the rifamycin group or those with methylene blue may be appropriate, as well as a surgical caveat to thoroughly wash out the anterior chamber after using trypan blue. To my knowledge,
First author: Lance S. Ferguson, MD Commonwealth Eye Surgery Lexington, Kentucky, USA
J CATARACT REFRACT SURG - VOL 34, FEBRUARY 2008