Venkatesh R, James E, Hande P, Raj P, Tendulkar K, Prabhu V. Retinal architecture as a determinant of brilliant blue G phototoxicity during internal limiting membrane peeling: A case series. World J Clin Cases 2026; 14(4): 117314 [PMID: 41695761 DOI: 10.12998/wjcc.v14.i4.117314]
Corresponding Author of This Article
Ramesh Venkatesh, MBBS, Consultant, Department of Ophthalmology, Narayana Nethralaya, 121/C. 1st R block, West of Chord Road, Rajaji Nagar, Bangalore 560010, India. vramesh80@yahoo.com
Research Domain of This Article
Ophthalmology
Article-Type of This Article
Case Control Study
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Feb 6, 2026 (publication date) through Mar 4, 2026
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Journal Information of This Article
Publication Name
World Journal of Clinical Cases
ISSN
2307-8960
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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
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Venkatesh R, James E, Hande P, Raj P, Tendulkar K, Prabhu V. Retinal architecture as a determinant of brilliant blue G phototoxicity during internal limiting membrane peeling: A case series. World J Clin Cases 2026; 14(4): 117314 [PMID: 41695761 DOI: 10.12998/wjcc.v14.i4.117314]
Ramesh Venkatesh, Prathibha Hande, Pragati Raj, Karishma Tendulkar, Vishma Prabhu, Department of Ophthalmology, Narayana Nethralaya, Bangalore 560010, India
Edwin James, Department of Ophthalmology, Government Medical College Kollam, Kollam 691574, Kerala, India
Co-first authors: Ramesh Venkatesh and Prathibha Hande.
Author contributions: Venkatesh R and Hande P were responsible for the clinical management of the cases and analyzing the cases, drafting and finalizing the manuscript; James E was responsible for the critical review of the manuscript; Prabhu V, Tendulkar K, and Raj P were responsible for data acquisition and image collection.
Institutional review board statement: This study was conducted in accordance with the tenets of the Declaration of Helsinki. Institutional ethics committee approval was obtained from the Narayana Nethralaya Ethics Committee, Bangalore, India (EC Ref. No: C/2019/03/04). Given the retrospective nature of the study and the use of anonymized clinical data, the requirement for informed patient consent was waived by the Ethics Committee.
Informed consent statement: Informed consent was waived by the Institutional Ethics Committee due to the retrospective design of the study and the use of de-identified patient data with no direct patient involvement.
Conflict-of-interest statement: All authors declare that they have no conflicts of interest relevant to this study.
STROBE statement: The authors have read the STROBE statement-checklist of items, and the manuscript was prepared and revised according to the STROBE statement-checklist of items.
Data sharing statement: The data supporting the findings of this study are available from the corresponding author upon reasonable request, subject to institutional and ethical regulations.
Corresponding author: Ramesh Venkatesh, MBBS, Consultant, Department of Ophthalmology, Narayana Nethralaya, 121/C. 1st R block, West of Chord Road, Rajaji Nagar, Bangalore 560010, India. vramesh80@yahoo.com
Received: December 4, 2025 Revised: December 19, 2025 Accepted: January 19, 2026 Published online: February 6, 2026 Processing time: 63 Days and 6.9 Hours
Abstract
BACKGROUND
Chromovitrectomy using vital dyes has become integral to internal limiting membrane (ILM) peeling in macular surgery. Although brilliant blue G (BBG) is considered safer than earlier dyes, emerging clinical and experimental evidence suggests that dye-light interactions during surgery may result in retinal phototoxicity under specific conditions.
AIM
To describe the retinal phototoxicity features associated with BBG dye in patients undergoing ILM peeling for macular surgeries.
METHODS
This observational, comparative, retrospective case series analyzed 9 eyes of 9 patients demonstrating retinal phototoxicity after uneventful BBG-assisted ILM peeling. Surgical indications included full-thickness macular hole (MH) in 4 eyes, epiretinal membrane associated retinal traction in 4 eyes, and vitreomacular traction in 1 eye. Retinal phototoxicity was assessed during clinical examination, using optical coherence tomography, and fundus autofluorescence imaging. Parameters such as preoperative and postoperative visual acuity (VA), macular thickness, BBG exposure characteristics (single/repeated staining, exposure duration, staining medium), and follow-up outcomes were recorded. Cases were grouped based on surgical indications: Group A (MH, 4 eyes) and group B (non-MH, 5 eyes).
RESULTS
In group A, all cases showed foveal phototoxic damage along with macular involvement despite successful MH closure. Two eyes experienced worsened VA, while the other two maintained baseline VA. In group B, phototoxicity involved the macular region but spared the fovea; VA improved in 3 eyes (60%) and was maintained in 2 eyes (40%). Retinal toxicity, characterized by photoreceptor and retinal pigment epithelium damage, was evident within 1-4 weeks postoperatively.
CONCLUSION
BBG-related retinal phototoxicity may occur following ILM peeling, with eyes undergoing MH surgery appearing more vulnerable, possibly due to the absence of protective foveal neurosensory tissue. Awareness of this potential risk may encourage surgeons to consider minimizing illumination intensity and dye exposure, and to adopt protective intraoperative strategies aimed at preserving foveal integrity and optimizing visual outcomes.
Core Tip: This case series identifies retinal architecture as a key determinant of brilliant blue G (BBG)-related toxicity during internal limiting membrane peeling. Phototoxicity was more severe in macular hole (MH) cases where the exposed retinal pigment epithelium allowed direct BBG-light interaction, leading to foveal damage and poor visual recovery. Non-MH eyes, including epiretinal membrane and vitreomacular traction, retained foveal protection and demonstrated better postoperative vision. The study reinforces careful control of illumination and BBG exposure in MH surgery.
