Corneal edema after descemet membrane stripping automated endothelial keratoplasty with the use of gentian violet staining.

In recent years, endothelial keratoplasty has been commonly used as an alternative to penetrating keratoplasty as a surgical treatment for corneal endothelial pathologies. The most common form of endothelial keratoplasty is Descemet membrane stripping automated endothelial keratoplasty (DSAEK), which involves stripping the host’s Descemet membrane and endothelium and replacing them with donor posterior stroma and endothelium. To delineate the orientation of donor DSAEK tissue, it is often marked by gentian violet (GV) dye on its stromal side. Gentian violet has long been thought to be nontoxic. However, using a standard rabbit eye irritation test, Ballantyne et al found that GV produced blepharitis, edema, and necrosis of the conjunctivae and nictitating membrane, keratitis, and elevation of intraocular pressure. Two subsequent studies discovered an increased incidence of corneal edema following the injection of GV solutions into the anterior chamber of the human eye during cataract surgery. Chang et al later discovered cell damage to rabbit corneal endothelium after exposure to GV. Furthermore, a dose-response relationship was exhibited in the study by Chang et al. Most recently, using a vital dye assay on a human donor cornea, Ide et al demonstrated that marking the DSAEK donor stromal surface with a GV marking pen damaged the corneal endothelium. These studies support the hypothesis that GV dye is toxic to the corneal endothelium. Currently, however, there is no evidence that the changes to the corneal endothelium caused by GV are clinically significant, but the potential longterm effects are still unknown. For this report of cases, we present 2 patients who underwent DSAEK with donor grafts marked with GV to demonstrate that GV may cause clinically significant edema. The grafts, which are typically between 80 and 150 μm thick, were marked with an “S” on their stromal side using a metal stamp. First, ink from an Accu-Line P-2 skin marking pen was pooled onto the processing technician’s sterile glove. The ink was then transferred from the glove to the stamp. After waiting a few seconds for the ink to dry, we gently pressed the stamp against the stromal side of the graft. The eye bank that we use provides the “S” on the graft unless a surgeon specifically requests not to have it present. The mean(SD)volumeof ink in theAccuLineP-2skinmarkingpen is1.4 (0.1) g, with 3% to 8% of this being GV dye by weight. The 2 cases were from different batches of GV markers.