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Comment on: ‘The use of fluorinated gases and quantification of carbon emission for common vitreoretinal procedures’

Eye volume 38, page 225 (2024)Cite this article

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Having read with interest the article “The use of fluorinated gases and quantification of carbon emission for common vitreoretinal procedures” by Moussa et al. [1] we would like to express the importance of this topic additionally for the cornea surgeons that perform Descemet’s membrane endothelial keratoplasty (DMEK). In order to achieve adherence of the donor tissue in DMEK surgery a tamponade is used with either 100% air or some opt for 20% SF6. A recent survey of UK DMEK surgeons found the majority of those that responded, used air tamponade over SF6 (66.67% of surgeons used air tamponade), and air was used by the majority for rebubble procedures (83.33%) [2]. The response rate of this survey was however rather low, 20% response rate, 30 surgeons responded of the 150 surveyed, and it is possible therefore that more surgeons use SF6 first line both nationally and internationally. Some surgeons opt for SF6 over air as it lasts longer in the eye, and therefore it may lead to better graft adherence, though the evidence for this is limited and most of the studies that quote a lower detachment rate with SF6 are older studies [3]. Since these studies have been published, more surgeons and units are likely to be performing DMEK with better outcomes, therefore the detachment rates are likely to be lower for all cases, including those for which air is used. As discussed in the article by Moussa et al. 2023, the use of SF6 causes significantly higher carbon emissions than C2F6 and C3F8 in VR surgery [1]. Furthermore, SF6 is the most potent greenhouse gas known [4]. Given that with corneal surgery the option exists to use air rather than SF6, we should question the use of SF6 for these procedures, particularly for eyes that do not have any co-pathology and therefore may be at lower risk of graft detachment. We can thus ensure that our surgery not only helps patients improve their vision, but also helps to minimise the resultant carbon emission contributions. Evidence based protocols may therefore also help in corneal endothelial keratoplasty surgery to make this surgery ‘greener’.

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References

  1. Moussa G, Ch'ng SW, Ziaei H, Jalil A, Park DY, Patton N, et al. The use of fluorinated gases and quantification of carbon emission for common vitreoretinal procedures. Eye. 2023;37:1405–9.

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  2. Diab, RA, Zarei-Ghanavati M, Bardan AS, Vasquez Perez A, Liu G, Goweida MB, et al. “Preferred Practices of Descemet’s Membrane Endothelial Keratoplasty (DMEK) Surgeons in the UK: A National Survey.” J EuCornea. 2022;11.

  3. Marques RE, Guerra PS, Sousa DC, Ferreira NP, Gonçalves AI, Quintas AM, et al. Sulfur Hexafluoride 20% Versus Air 100% for Anterior Chamber Tamponade in DMEK: A Meta-Analysis. Cornea. 2018;37:691–7.

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  4. IPCC. IPCC Fourth Assessment Report (AR4), Working Group 1. Chapter 2, Changes in atmospheric constituents and in radiative forcing. Intergovernmental Panel on Climate Change (IPCC); 2007.

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  1. Consultant Ophthalmologist and Cornea Surgeon, Department of Ophthalmology, Royal United Hospital, Bath, UK

    Shokufeh Tavassoli

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Correspondence to Shokufeh Tavassoli.

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Tavassoli, S. Comment on: ‘The use of fluorinated gases and quantification of carbon emission for common vitreoretinal procedures’. Eye 38, 225 (2024). https://doi.org/10.1038/s41433-023-02651-4

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