Case Series of Inappropriate Concentration of Intraocular Sulfur Hexafluoride

• 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
• ISSN: 1663-2699; 1663-2699
• DOI: 10.1159/000492746

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%.