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Acute retinal toxicity associated with a mixture of perfluorooctane and perfluorohexyloctane: failure of another indirect cytotoxicity analysis
  1. Rosa M Coco1,2,
  2. Girish K Srivastava1,3,
  3. Cristina Andrés-Iglesias4,5,
  4. Jesús Medina4,
  5. Fernando Rull4,
  6. Alvaro Fernandez-Vega-Gonzalez6,
  7. Ivan Fernandez-Bueno1,2,3,
  8. Antonio Dueñas1,7,
  9. Jose C Pastor1,2,8
  1. 1 Instituto Universitario de Oftalmobiología Aplicada (IOBA), Eye Institute, University of Valladolid, Valladolid, Spain
  2. 2 Red Temática de Investigacion Cooperativa en Salud de Oftalmologia (Oftared), Instituto de Salud Carlos III, Madrid, Spain
  3. 3 Centro en Red de Medicina Regenerativa y Terapia Celular, Junta de Castilla y Leon, Valladolid, Spain
  4. 4 Departament of Physics of Condensed Matter, Crystallography and Mineralogy, University of Valladolid, Valladolid, Spain
  5. 5 High Pressure Processes Group, Department of Chemical Engineering and Environmental Technology, University of Valladolid, Valladolid, Spain
  6. 6 Instituto Oftalmologico Fernandez-Vega, Oviedo, Spain
  7. 7 Toxicology Department, University of Valladolid, Valladolid, Spain
  8. 8 Department of Ophthalmology, Hospital Clinico Universitario of Valladolid, Valladolid, Spain
  1. Correspondence to Dr Girish K Srivastava, Instituto Universitario de Oftalmobiología Aplicada (IOBA), Eye Institute, University of Valladolid, Valladolid 47011, Spain; girish{at}


Aims To report new information related to acute retinal toxicity of Bio Octane Plus, a mixture of 90% perfluorooctane (PFO) and 10% perfluorohexyloctane.

Methods This retrospective, descriptive case series reports the occurrence of acute retinal toxicity after vitreoretinal surgery in which Bio Octane Plus (batch number 1605148) was used as an endotamponade. Cytotoxicity biocompatibility tests and chemical analyses by Fourier-transformed infrared (FTIR) spectroscopy and gas chromatography-mass spectrometry (GC-MS) of the presumed toxic product were performed.

Results Four patients presented with acute severe visual loss after uneventful ocular surgery assisted by Bio Octane Plus (batch number 1605148) as endotamponade. Patients experienced extensive retinal vascular occlusion leading to retinal and optic nerve atrophy. The viability of ARPE-19 cells directly exposed to the suspect batch for 30 min was 0%. The agarose overlay method used by the manufacturer according to European Union regulations and International Organization for Standardization (ISO) International Standards failed to detect toxicity. FTIR spectroscopy showed small differences between the non-toxic and toxic batches. GC-MS analysis showed the presence of bromotributyl stannane (whose toxicity was demonstrated in the dose–response curve) only in the toxic batch of Bio Octane Plus.

Conclusion This is the third report of retinotoxicity due to PFO in 4 years. The clinical profiles may be missed as they resemble other postsurgical complications; therefore, more cases worldwide could have gone unreported. Protocols to determine cytotoxicity of intraocular medical devices and approved by the ISO International Standards based on indirect methods have failed and should be revised to ensure safety.

  • perfluorooctane
  • perfluorohexyloctane
  • tributyltin bromide
  • organotins
  • retinal toxicity
  • retinal vascular occlusion
  • optic atrophy
  • retinal atrophy
  • regulatory and medical devices norms
  • tests for safety of endotamponades

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  • Contributors RMC wrote the paper and contributed to drafting the work for important intellectual content. GKS and IF-B contributed to the conception and design of the work, the analysis and interpretation of cytotoxicity test data. JM, CA-I and FR contributed to the conception and design of the work, the acquisition, analysis or interpretation of data on structural and chemical tests. AFV-G contributed to the write clinical data. AD identified the toxicity of the chemical compounds. JCP and FR contributed to drafting the work for important intellectual content. All authors are responsible for the final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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