Les Cahiers N.

125 - December 2008

Vitreoretinal surgery

Fluorinated expansive gases: indispensable tools

Jean-Paul Berrod

luorinated expansive gases were first used in 1973 by Norton, Machemer and
F Vygantas, but due to Lincoff there were numerous publications on this type of
tamponade during the eighties.
Today, internal tamponade by a mixture of non-expansive air and sulphur hexafluoride
SF6 remains the premier type of tamponade after vitrectomy for detached retina or
macular hole.

Characteristics of fluorinated
expansive gases
Injected pure into the vitreous cavity, the fluorinated
gases initial volume is increased by absorption of the
blood nitrogen. This gives them two essential proper-
ties compared to air: the possibility of gaining a larger
intraocular volume and greater internal tamponade
surface for the same amount injected and prolonged
tamponade, the resorption of gas being slower than
that of air. The rate of expansion and the length of action
vary according to the gas used.

Physical properties of sulphur hexafluoride,

perfluoroethane and perfluoropropane
The three main fluorinated gases used currently
in France are: sulphur hexafluoride (SF6), perfluoroe-
thane (C2F6) and perfluoropropane (C3F8). The volume
of pure SF6 doubles in 48 hours after injection, total
resorption takes 15 to 17 days.
The volume of C2F6 multiplies by 3, total resorption
takes a month, while that of C3F8 quadruples and is re-
sorbed in two months (figure 1).
Ophthalmology Hospital Division A,
Central Hospital, Nancy, France
Figure 1.Presentation of three ophthalmic gases kits.
Severe myopia reduces the speed of resorption of the
gas, total disappearance of the bubble can take up to
three months, while the inflammation and the hemato-
retinal barrier breakdown accelerate resorption.
The gas bubble, its volume and positioning
To induce an effective tamponade, the gas bubble
must have a volume sufficient to cover all the retinal
tears. After injection, the bubble is positioned at the
highest part of the vitreous cavity. The arc of contact
of the bubble with the retina will be even shorter if
the globe is myopic. For an eye of normal axial length
(23 mm), a bubble of 0.4 ml has an arc of contact of 90°
whereas a bubble of 1 ml has an arc of contact of 110°
and a bubble of 2.5 ml an arc of 180°. An intravitreous
bubble which covers the whole area of dehiscence
isolates the tears in the vitreous cavity and stops the
passage of vitreous under the retina. In this way, the
gas bubble blocks off the tears during healing of the
retinopexy. The gas bubble acts also in the manner of
a blunt endocular instrument that reacts to the move-
ments of the patient’s head, which justifies the pres-
cription of strict post-operative positioning.
Which gas to choose?
The choice of gas must be adapted to each patient,
according to the type of detachment and the type of
procedure.
The gases of short duration (air, SF6) are recom-
mended in non-vitrectomised eyes. In retinal detach-
ment surgery (RD) by cryo-indentation external
procedure, the role of the gas bubble is to block or
avoid «fishmouth» of the tear on the indentation. Air is
preferable in the majority of cases when the volume of
gas injected is sufficient to block the tear; however a
bubble less than 0.4 ml has little chance to be effective.
SF6 can be used without creating a hypertony when the
injected volume is too weak to block off the dehiscences
(< 0.4 ml). It will be beneficial when the expansion effect
of the bubble reaches an effective size (0.4 to 0.8 ml) in
24 to 48 hours.
SF6, C2F6, C3F8: utilisation principles
The principles of use are the same as for air: the gas
is taken under sterile conditions into a syringe through
a Millipore filter linked by a tubing to a bottle fitted with
a regulator and a flowmeter. After flushing the tubing
between the syringe and the bottle, the gas is gathered,
then injected into the pars plana in the vitreal cavity,
while digitallly controlling the ocular tonus. There are
also kits dedicated to intraocular injection of gas com-
prising a can of pressurised gas (SF6, C2F6, C3F8), a
filter and a 60 ml syringe.
The syringe fitted with a filter will puncture the can
and is filled with the pressurized gas which is then di-
luted with air (figure 2).
In the case of an external procedure, it is necessary
to drain a volume of sub-retinal fluid equivalent to the
volume of injected gas, in order to avoid any per- and
post-operative hypertony. In certain cases, in particu-
lar in strong myopia, hemorrhagic risks linked to drai-
2 Les Cahiers
ning the sub-retinal fluid can be avoi-
ded, by draining the anterior cham-
ber repeatedly until 0.5 ml of the
total volume has been extracted.
Figure 2.Using an expansive
ophthalmic gas kit.
Indication of expansive gas
in RD surgery without vitrectomy
Subsequent to an indentation
The injection of a bubble of SF6 at the end of indenta-
tion counteracts the «fishmouth» phenomenon which
is the formation, after putting in place the indentation,
of a radial fold from the posterior lip of the tear. This
radial fold is like a tunnel allowing vitreous fluid to pass
under the retina, preventing its good reattachment. The
risk factors of «fishmouth» are the bulbous character
of the RD, the preoperative existence of a radial fold, a
tear greater than the papillary diameter, a very protru-
ding indentation parallel to the limbus. In all cases, the
injection of a gas bubble avoids the failure of reattach-
ment by the «fishmouth» phenomenon.
Internal tamponade of the tear far from the indenta-
tion is the most frequent indication of the injection of
a gas bubble. This can even be used alone without
indentation in pneumatic retinopexy.
Injection of gas alone: pneumatic retinopexy
is less practised in France
Pneumatic retinopexy is a non-invasive treatment of
retinal detachment attainable by ambulatory method,
proposed by GF Hilton in 1987. It consists of conducting
a cryoattachment of the detachment under topical
anaesthetic, followed by an intravitreous injection
of 0.3 ml of C3F8. The patient is strictly positioned
for several days afterwards so that the gas bubble
blocks the tear until the sub-retinal fluid is completely
reabsorbed. The intraocular tonus is adjusted only by
possibly draining the anterior chamber. The indica-
tions are single ruptures of less than papilla diameter
sitting above the horizontal meridians without sign
of vitreo-retinal proliferation (VRP).
This technique can be applied equally to macular
holes or to tears in the posterior pole. According to
studies, the rate of success during the first operation
is in the order of 80 %, recurrences being linked to the
appearance of a new inferior tear in 13 % of patients
and a VRP in 4 % of eyes. Although simple to conduct,
this technique remains seldom practised in France
because of a high rate of recurrences and administra-
tive difficulties in conducting ambulatory vitreo-retinal
surgery.
Precautions in the use of expansive gas
on a non vitrectomised eye
It is important to watch out for the absence of any
hypertony greater than 25 mmHg after injecting the
gas bubble, to guarantee the absence of occlusion of
the central artery of the retina, particularly in patients
with glaucoma. The hypertony must always be avoided
or controlled by draining the amount of sub-retinal
fluid close to that of the injected bubble. The maximum
volume of pure gas that can be injected into the non-
vitrectomised eyeball and after draining the sub-
Figure 3.Pure gas injection in an eye which Figure 4.Bubble injection.
did not undergo vitrectomy: management of
the needle positioning.
Figures 6 and 7.Carrying on with the injection.
retinal fluid is 2 ml for SF6, 1 ml for C2F6 and 0.5 ml
for C3F8. In the case of glaucoma, air should be the
favourite choice.
The bubble is injected onto the pars plana at more
than 3 mm from the limbus, under microscopic control,
with a 30 gauge needle by first directing the bevelled
edge towards the centre of the eye. Then, without plun-
ging the needle up to the hilt, the retina is close enough
and is injected quickly so as to avoid the formation of
fish egg micro-bubbles (figures 3 to 7). It is important
to control the positioning of the extremity of the needle
under the microscope so as to be sure of not injecting
the gas under the retina (figure 8) nor to bring about a
cataract.
Indication of expansive gases after
vitrectomy through the pars plana
After vitrectomy through the pars plana, this leads
on to conducting a filling with a mixture of air and gas in
detached retina or macular hole surgery. Two different
techniques are used depending on that chosen by the
surgeon.
Figure 5.Bubble fragmentation
during injection.
Figure 8.Total retinal detachment 24 hours
after ectopic C2F6 injection underneath
the retina in an eye which did not undergo
vitrectomy.
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The dart technique
At the end of vitrectomy, the eyeball is left under
water and the sclerectomies are sutured tightly
A mixture of 50 % air with 50 % filtered SF6 prepared
in a 3 ml syringe is injected onto the pars plana by hand
using a 30 gauge needle, while the other hand is used
to introduce a 25 gauge needle up to the hilt in the
second sclerotomy. This second longer needle evacua-
tes under pressure approximately half the endocular
fluid so that the eyeball will be half filled with a mixture
of 50 % SF6. This expansive mixture will fill the whole
vitreous cavity of the emmetropic eye in 48 hours.
The technique of total fluid-air exchange
At the end of vitrectomy, the infusion terminal is
connected to vacuum function set at 35 mmHg and the
endocular fluid is then actively withdrawn, at the site of
tears or of the papilla, so as to obtain a totally dry eye
and a completely reattached retina. A very weak ex-
pansive mixture of air and SF6 (27.7 %) is prepared in
a 50 ml syringe by first taking 18 ml SF6 then by filling
it with air up to the stopper, which is 65 ml. This syringe
is then plugged onto the terminal in place of the
vacuum inlet. 4/5 of the syringe is emptied into the
ocular globe; a sclerotomy is kept open by a cannula.
Then the two upper sclerotomies are sutured, the
endocular pressure is adjusted and the terminal is
then withdrawn and its sclerotomy sutured.
If a longer tamponade is required such as in the
case of VRP, a strong myopic patient or for macular
holes longer than 600 microns, a mixture of 20 %
air/C2F6 is used by putting 13 ml of filtered C2F6 into
a 50 ml syringe and topping it up with air until the
stopper, which is 65 ml. In order to obtain a tamponade
of two months, 10 ml C3F8 is taken in the same way
into the syringe and by filling up to 65 ml with air.
Cataract, severe hypertony…
preventing complications
The most frequent complication is cataract by des-
siccation linked to the contact with gas on the posterior
capsule (figure 9). This can be prevented by placing
the patient’s head in a downward position. It usually
disappears after resorption of the gas.
A moderate hypertony of less than 3 mmHg is fre-
quent for several days. It is prevented by systematic ad-
ministration of acetazolamide per os for 24 to 48 hours,
also by the prescription of hypotonising eye drops for
the first half of the tamponade period. A severe hyper-
tony the day after the operation with epithelial conden-
4 Les Cahiers
Figure 9.Cataract
resulting from
desiccation 24 hours
after a full fluid
gas exchange.
sation is most likely due to an error in the dilution and
requires urgent puncture of the posterior segment
in order to avoid acute ischemia of the eyeball. In all
cases it is necessary to contra-indicate spending
periods at high altitude or air travel which are likely to
increase the volume of the bubble by ambient depres-
surisation, as well as the use of nitrogen protoxide
during a general anaesthetic.
The passage of gas into the anterior chamber is
possible in pseudophakic patients or strong myopes.
A bubble greater than 50 % of the volume of the ante-
rior chamber should be withdrawn in order to avoid a
hypertonia or endothelial decompensation. In the case
of an aphakic patient, tamponade by total gas bubble
can lead to the iris leaning towards the cornea. It is ad-
visable to practice an inferior peripheral iridectomy
and to ask the patient to keep his head downwards fol-
lowing surgery.
Indispensable tools
to be well understood
Expansive gases are indispensable post-operative
tools for prolonging internal tamponade of the retina
until complete healing of a macular hole or detached
retina retinopexy. Their rational use necessitates good
knowledge of their physical characteristics in order to
manage their dilution and to adapt the type of tampo-
nade appropriate to the underlying retinal pathology.
Bibliography
Bonnet M. Microsurgery of retinal detachment. Springer-Verlag 1989:
115-31.
Brasseur G et al. Pathologie du vitré. Rapport SFO 2003. Masson:
421-44.
Ryan SJ et al. Retina. Elsevier Health Sciences 1994: 2093-129.