Double staining with brilliant blue G and double peeling for epiretinal membranes

Ophthalmology. 2009 Jul;116(7):1370-6. doi: 10.1016/j.ophtha.2009.01.024. Epub 2009 May 8.


Purpose: To compare methods of removing epiretinal membranes (ERM) and evaluate the usefulness of the double brilliant blue G (BBG) staining and double-peeling method.

Design: Prospective, interventional case series.

Participants: We followed 246 consecutive patients who underwent pars plana vitrectomy to remove ERM and for > or =12 months.

Methods: Of the 246 eyes, 104 underwent single ERM peeling using indocyanine green staining, and 142 underwent ERM peeling by 1 of the 3 following methods: without staining in 46 eyes, triamcinolone acetonide staining in 42, and BBG staining in 54. Peeling of residual internal limiting membrane (ILM) was then conducted using BBG. In the latter group, the ILM that remained after the initial peeling procedure was evaluated macroscopically with BBG staining and also histopathologically. In 6 eyes requiring reoperation owing to ERM recurrence, the peeled ERM was examined histopathologically.

Main outcome measures: Postoperative visual acuity and recurrence of ERM.

Results: The ERM recurrence rate was 16.3% (17 eyes) and the reoperation rate was 5.8% (6 eyes) among the 104 eyes that underwent single ERM peeling, compared with 0% in 142 eyes with double ERM and ILM peeling. Although the ERM recurrence rate was significantly lower with double peeling, postoperative visual acuity did not differ between the 2 methods. The 3 ERM peeling methods differed in the rate and extent of residual ILM, and the lowest rate (21/54 eyes; 39%) was achieved with BBG staining (P<0.0001). Histopathologic examination of the ILM remaining after ERM peeling detected remnant ERM cells on the ILM. Histopathologic examination of the peeled ERM in 6 eyes with ERM recurrence showed residual ILM to serve as a scaffold for cell proliferation.

Conclusions: This study verified that ERM recurrence arises from remnant ERM components on the ILM, which proliferate using the ILM as a scaffold, and that complete ILM removal seems to reduce the risk of recurrence. Brilliant blue G with good affinity for the ILM facilitates simultaneous ERM and ILM peeling in many cases, and BBG contact with the retina in the second staining has no apparent effect on visual acuity. Double BBG staining and double peeling is useful for ERM treatment.

Publication types

  • Comparative Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Basement Membrane / pathology
  • Basement Membrane / surgery*
  • Coloring Agents*
  • Epiretinal Membrane / diagnosis
  • Epiretinal Membrane / surgery*
  • Female
  • Humans
  • Indocyanine Green
  • Male
  • Middle Aged
  • Prospective Studies
  • Recurrence
  • Rosaniline Dyes*
  • Staining and Labeling / methods
  • Triamcinolone Acetonide
  • Visual Acuity / physiology
  • Vitrectomy / methods*


  • Coloring Agents
  • Rosaniline Dyes
  • Triamcinolone Acetonide
  • Indocyanine Green
  • coomassie Brilliant Blue