Case Series of Inappropriate Concentration of Intraocular Sulfur Hexafluoride

Due to high complexity, vitreoretinal surgery presents a higher number of patient safety incidents compared with other ophthalmic procedures. Intraocular gases are one of the most useful adjuncts to vitrectomy and surprisingly, surgeons commonly admit to having occasional problems with incorrect gas...

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Bibliographic Details
Published in:Case reports in ophthalmology 2018-08, Vol.9 (2), p.405-410
Main Authors: Kanclerz, Piotr, Grzybowski, Andrzej
Format: Article
Language:English
Subjects:
Case Report
Case reports
Cataracts
Expandable gas
Eye surgery
Gases
Human error
Intraocular pressure
Intraocular tamponade
Ophthalmology
Patient safety
Sulfur
Sulfur hexafluoride
Surgeons
Vitrectomy
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Summary:Due to high complexity, vitreoretinal surgery presents a higher number of patient safety incidents compared with other ophthalmic procedures. Intraocular gases are one of the most useful adjuncts to vitrectomy and surprisingly, surgeons commonly admit to having occasional problems with incorrect gas concentration. The aim of this study is to present a consecutive case series of patients with improper concentration of sulfur hexafluoride (SF 6 ) applied during vitrectomy. Three patients underwent 27-gauge vitrectomy and at the end of surgery inappropriate dilution of 100% SF 6 was administered. It was attributed to a calculation error, change in the gas supplier, or increased partial pressure of SF 6 before dilution. Postoperatively, due to IOP increase, two eyes required intravitreal gas-air exchange. Subsequently, cataract surgery was performed in one eye with concomitant vitrectomy and silicone oil tamponade due to retinal detachment. To prevent such complications, we suggest using intraocular gases with great care, training of ophthalmic personnel, and prompting manufacturers to provide SF 6 in a prepared concentration of 20%.
ISSN:1663-2699
1663-2699
DOI:10.1159/000492746