Consensus Recommendations on the use of PFAS-containing ocular endotamponades

Purpose: To develop recommendations on the use of per- and polyfluoroalkyl substances (PFAS)-containing ocular endotamponades (OEs) in vitreoretinal surgery. Methods: We conducted an expert-led consensus using a modified Delphi methodology with panel consisting of fourteen vitreoretinal surgeons and five representatives of companies involved in OEs production and marketing. Based on a literature review and the latest updates on European Union's PFAS restriction proposal, the facilitator prepared a list of statements on PFAS-containing OEs currently used. Each statement was graded individually using a nine-point scale (from 1 "absolutely disagree" to 9 "absolutely agree") and the consensus was defined as a score between 7 and 9 from ≥80% of members. Results: After two rounds, and related discussion, the recommendations highlighted the crucial role of PFAS-containing OEs in surgical practice and the potential negative impact of their ban on patients' outcomes. There was a strong agreement on the need of perfluorocarbon liquids as intraoperative tool, although it was also pointed out that their use should be avoided if possible. Fluorinated gases were deemed essential with no agreement on the possibility to replace SF6 and/or C2F6 with C3F8 at different concentrations. Conversely, semifluorinated alkanes as rinsing solution as well as F6H8 were considered extraneous. No consensus was reached about the current role of heavy silicone oils. Finally, the use of air as alternative and environment-friendly OE was judged not supported by sufficient evidence but worth of further investigation. Conclusions: The consensus panel developed recommendations aimed at promoting a more sustainable surgical practice.