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StudyThe British journal of ophthalmology · 2026

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).

Fernando J Huelin, Peter Kiraly, George Moussa … on behalf ofBEAVRS board

OphthalmologyStudy

Over a third of UK vitreoretinal surgeons recall harm from wrong gas concentration

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).

Fernando J Huelin … on behalf ofBEAVRS board

The British journal of ophthalmology · 2026

Background

Errors in intravitreal fluorinated gas selection or dilution can result in unintended expansile concentrations, causing irreversible visual loss.

Purpose

We 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.

Methods

NHS England patient safety incident repositories (National Reporting and Learning System and Learn from Patient Safety Events) were searched for events related to intravitreal gas use (2010-2025), followed by thematic analysis.

n = 29 cases

Results

over a third of surgeons recall a serious complication from a wrong gas mix

Recalled significant c

38.9%

Witnessed sight-threat

16.7%

More results

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.

More results

The literature review identified 20 severe cases across 11 publications.

“

Conclusion · 1 of 2

Incorrect intraocular gas concentration is likely under-reported but can cause devastating, preventable harm.

Conclusion · 2 of 2

Standardised systems for storage, preparation, verification and postoperative review may reduce risk while supporting environmentally responsible practice.

Post

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).

Over a third of UK vitreoretinal surgeons recall harm from wrong gas concentration

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