Safe use of fluorinated gases in vitreoretinal surgery: learning from patient safety incidents with expert panel recommendations from the British and Eire Association of Vitreoretinal Surgeons (BEAVRS)

Summary

Errors in intravitreal fluorinated gas selection or dilution can result in unintended expansile concentrations, causing irreversible visual loss. This study aimed to quantify the problem using national incident reporting, published literature and a UK surgeon survey, developing expert consensus recommendations on safe storage, handling and intraocular use.

Content

National reporting identified 47 relevant incidents; 29 cases involved incorrect gas concentration due to preparation errors. 14 cases resulted in at least moderate harm, including eight with blindness or severe visual impairment; pure gas concentration (100%) administration was documented in six cases. The literature review identified 20 severe cases across 11 publications. Among 108 BEAVRS respondents, 38.9% recalled at least one significant complication related to incorrect gas concentration; 16.7% reported witnessing sight-threatening outcomes, most commonly central retinal artery occlusion.

Recommendations focused on clear labelling/colour coding, standardised dilution protocols, staff training, mandatory two-person checks, appropriate use and segregation of pre-mixed iso-expansile gases and adjunctive safety measures (gas cards/wristbands).

The authors of the study concluded that incorrect intraocular gas concentration is likely under-reported but can cause devastating, preventable harm. Standardised systems for storage, preparation, verification and postoperative review may reduce risk while supporting environmentally responsible practice.