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To the Editor.
—We recently had an experience where a serious complication could have occurred due to faulty setup of vitrectomy instrumentation. During the course of a routine vitrectomy, we were given an aspiration needle, by the operating room staff, that expelled compressed air at high pressure. We were using a Daisy (Stortz Instrument Co, St Louis, Mo) microvitrectomy unit, and a check of the line revealed that the aspiration needle had been connected to the pneumatic driver for the vitrectomy handpiece rather than to the aspiration port. The Daisy microvitrectomy control unit puts out a pressure of 80 psi into the pneumatic driver, and, taking into account pressure loss through the line, the pressure is still about 30 psi (1500 mm Hg) at the microvitrectomy cutter. We could have injected compressed air at 1500 mm Hg into our patient's eye!This incident occurred when the operating room staff modified
Frambach DA, Ma C, Liggett PE. Modified Tubing Connections for Vitrectomy Can Be Dangerous. Arch Ophthalmol. 1990;108(6):781. doi:10.1001/archopht.1990.01070080023017
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