The use of perfluorooctane (C8F18) has been well-acclaimed in vitreoretinal surgery in terms of efficiency and safety.1 Several perfluorocarbon liquids-related ocular complications have been observed in in vitro studies, animal studies, and clinical follow-up including direct toxicity, inflammation, damage on retinal cells due to perfluorocarbon gravity, and retained subfoveal bubbles.2,3
More than 100 cases of severe visual loss in the immediate postoperative period after retinal detachment surgery were recently reported by a Spanish official health care agency, and in all cases the same perfluorooctane (ALA OCTA; Alamedics, Dornstadt, Germany) was used.4 The photography we present belongs to one of these patients who asked for a second opinion concerning this complication 1 month after the surgery. He referred a severe visual loss and presented with counting fingers vision.
The widefield retinography (Optos, Dunfermline, UK) shows a marked pallor of the temporal aspect of the optic disc and edema of the internal retinal layers (arrows), presumably related to an arteriolar occlusive phenomenon. Scars of laser photocoagulation blocking a retinal tear are present at the temporal mid-periphery. The optical coherence tomography (OCT) (Cirrus HD-OCT; Zeiss, Oberkochen, Germany) demonstrates a marked thinning and destruction of the central neurosensory retina with cavities and a retinoschisis-like appearance. Additionally, a central focal disruption of the outer retinal layers and loss of photoreceptors is noticed. A sheet of hyperreflective tissue in the inner retina is also noticed, which might correspond to cortical vitreous remnants or to a fibrocellular epiretinal proliferation. The retina within the papilomacular bundle seems to be more preserved. This area does not show edema in the widefield retinography, although some exudates seem to be present (Figure).
(Top) Widefield colored retinography of the patient. The edema of the internal retinal layers is marked with arrows. At the temporal midperiphery, scars of laser photocoagulation blocking a retinal tear can be found. Note the sectorial pallor of the optic disc. (Bottom) Optical coherence tomography showing the central neurosensory retina destruction.
Pastor et al.5 claims that some tests used to evaluate intraocular toxicity of the product by certified European agencies and accepted by International Organization for Standardization were not adequate. The manufacturer's testing was performed on the original raw material but not in the final product. Furthermore, the product was not tested in the same way as used during clinical use. These two precepts are completely faced to UNE-EN-ISO standards and European guidelines. Chang et al.6 concluded that the impurities in the perfluorooctane batches were undetected due to poor regulatory oversight.
The presumed acute toxicity of ALA OCTA was studied in vitro by means of retinal pigmented epithelium cell culture and neuroretina organotypic culture, which showed the potential cytotoxicity of some of the batches of the product for retinal pigmented epithelium cells and sensory retina in terms of apoptosis and tissue degeneration.4
To our knowledge, this is the first case report and photo essay of a direct and sudden retinal toxicity related to perfluorooctane. This event should be considered in patients with acute-onset visual loss after an uneventful vitreoretinal surgery for retinal detachment.
- Georgalas I, Ladas I, Tservakis I, et al. Perfluorocarbon liquids in vitreoretinal surgery: A review of applications and toxicity. Cutan Ocul Toxicol. 2011;30(4):251–262. doi:10.3109/15569527.2011.560915 [CrossRef]
- Inoue M, Iriyama A, Kadonosono K, Tamaki Y, Yanagi Y. Effects of perfluorocarbon liquids and silicone oil on human retinal pigment epithelial cells and retinal ganglion cells. Retina. 2009;29(5):677–681. doi:10.1097/IAE.0b013e318196fca1 [CrossRef]
- Shulman M, Sepah YJ, Chang S, Abrams GW, Do DV, Nguyen QD. Management of retained subretinal perfluorocarbon liquid. Ophthalmic Surg Lasers Imaging Retina. 2013;44(6):577–583. doi:10.3928/23258160-20131105-07 [CrossRef]
- Actualización de la información sobre el producto Ala Octa (perfluoroctano), utilizado en cirugía de retina: Resultado de los ensayos realizados sobre nuevos lotes y número de casos notificados. Agencia Española de Medicamentos y Productos Sanitarios website. http://www.aemps.gob.es/informa/notasInformativas/productosSanitarios/seguridad/2016/NI-PS_03-2016-ala-octa.htm. Published March 11, 2016.
- Pastor JC, Coco RM, Fernandez-Bueno I, et al. Acute retinal damage after using a toxic perfluoro-octane for vítreo-retinal surgery. Retina. 2017;37(6):1140–1151. doi:10.1097/IAE.0000000000001680 [CrossRef]
- Chang S, Simpson RN. Impure perfluorocarbon liquids: A preventable tragedy. Retina. 2017;37(6):1019–1020. doi:10.1097/IAE.0000000000001663 [CrossRef]