Every day, we use a variety of instruments in our practices, from forceps for suture removal to lacrimal probes that clear an obstruction, and everything in between. Cleanliness, lubrication, correct handling, and proper storage ensure an instrument’s proper performance. Additionally, inspection, troubleshooting, and a structured instrument maintenance program can actually lengthen the serviceable life of your surgical instruments. Ophthalmic instruments are an investment, and proper care and maintenance protect that investment.

Beyond the instruments themselves, we need to protect our patients first and foremost. Immediate Threat to Life (ITL) declarations related to improperly sterilized or high-level disinfected equipment have increased significantly in the last few years, according to a May 2017 article by The Joint Commission. In 2016, 74% of all ITL declarations were related to improperly sterilized or high-level disinfected (HLD) equipment. Consequences of failed sterilization processes can result in serious outcomes, including:

• Risk for contamination
• Potential outbreaks, such as HIV, hepatitis B and C, and bacterial infections
• Potential loss of Joint Commission accreditation
• Potential loss of deeming status from the Centers for Medicare & Medicaid Services (CMS)
• Negative publicity, with potential consequent revenue losses
• Litigation

One of the complications of inadequate or improper processing of ophthalmic instruments is toxic anterior segment syndrome (TASS). Although rare, TASS can have devastating effects. It occurs when a non-infectious agent enters the anterior chamber of the eye and causes an inflammatory reaction. This may lead to severe infection, such as endophthalmitis, severe visual impairment, or possible loss of the eye if not recognized and treated in a timely manner. While usually associated with cataract surgery, TASS can occur after any type of anterior segment surgery, including corneal suture removals if instruments are not properly sterilized. Cleaning agent residues, endotoxins, denatured ophthalmic viscoelastic devices, preservatives, and residues from sterilization processing can all induce TASS and cause severe damage to ocular tissue.

Initial steps to instrument care

The first step in proper instrument care is to know what you have and how to take care of it. Assign a person in the office to be responsible for all care and maintenance record keeping. This person does an initial inspection of the instruments, warranty information, and manufacturer-recommended care when instruments are first received. Also, he or she should develop a calendar for cleaning and inspection. Cleaning and inspecting instruments on a regularly scheduled basis helps identify those instruments in need of repair or replacement, thus minimizing downtime. Also, staff will be up to date on the status of all of your equipment.

You will need a dedicated space for your instruments. Properly organize them and separate by type, such as forceps, scissors, cannulae, etc. Individual, appropriately labeled storage bins help streamline the process of gathering instruments in a hurry. Pre-packed surgical kits in the office, similar to kits used in the operating room, are a great help when time is in short supply, because instruments that you commonly use together will be easily accessible.

Also, train your staff to recognize each instrument. A technician who doesn’t know what a pair of Jewelers forceps looks like can frustrate the provider and cause a delay in patient care when asked to retrieve the instrument. Create an office reference guide that teaches the difference between each type of instrument and what they are used for, and their proper care (see Table 1). A visual guide inside the door of wherever the instruments are stored, as well as the contents written on packs prior to sterilization, is valuable in teaching new staff to easily and quickly identify instruments.

Proper processing procedures

• Follow the manufacturer’s recommendations for sterilization, such as steam, ethylene oxide, or immediate-use steam sterilization.
• Three containers are required: hot soapy water, lubricant, hot rinse water.
• Allow adequate time for processing instruments according to the manufacturer’s instructions; otherwise, the cleaning and sterilization of the instruments will be ineffective.
• Identify a designated cleaning area and equipment specific to the cleaning of ophthalmic surgical instruments.
• Whenever possible, process ophthalmic surgical instruments separately from general surgical instruments and equipment to reduce the potential for cross-contamination by material or residue from the general surgical instruments.
• Pre-clean instruments immediately following use.
• Use only those cleaning agents recommended by the manufacturer.
• According to the most recent guidelines published by a task force comprising of ASCRS, AAO, and OOSS, a non-enzymatic cleaner is recommended for disinfection of all ophthalmic instruments because previous studies have shown that enzymatic residues on intraocular instruments are a leading cause of TASS. This task force referenced new studies that show the difficulty of eliminating microscopic enzyme residues, even with prompt, thorough rinsing.
• Pay particular attention to the specified concentration and pH of the cleaning agent as well as the recommended water quality.
• Perform final rinsing of the instrument with sterile, distilled, or deionized water, unless otherwise specified by the manufacturer.
• After each use, discard the water used to clean or rinse instruments.
• If using an ultrasonic cleaner to process the instruments, empty, clean, rinse, and dry it at least daily or, preferably, after each use.
• Clean and sterilize brushes and other cleaning tools as recommended by the manufacturer daily or, preferably, after each use.
• Properly maintain cleaning and sterilization equipment. Otherwise, foreign materials, such as endotoxins or heavy metals, may be deposited onto the instruments during processing and may induce TASS.

Correct handling

• Wear gloves at all times when dealing with cleaners and other chemicals. They also provide a minor resistance to sharp instruments.
• Only use instruments for their specifically designed purpose. For example, never use needle holders as pliers. This leads to improper alignment of the jaws.
• Scissor points are extremely delicate, so do not touch the tips. Misuse of tissue scissors can easily dull or chip the cutting edge and misalign the blades. Also, never use them to cut paper.
• Use artery forceps or hemostats to remove the blade from blade handles. Point the cutting edge of the blade downward and always facing away from the body while trying to remove the blade.

Cleanliness

• Since ophthalmic instruments are very delicate, do not throw steel instruments into steel containers. This could result in chipped edges and bent tines. A medical-grade plastic tank with a removable tray, like the Miltex sterilization soaking tray, is the most prudent container for this purpose. The lifting tray helps mitigate the danger of sticking your hand into a tray of instruments.
• Use silicone-tipped tongs to remove instruments from soaking containers to avoid reaching into a group of sharp instruments.
• Wash away all tissue and bodily fluids from instruments prior to sterilization.
• Never allow blood or debris to dry on or inside instruments. Baked-on blood can result in corrosion and subsequent cracking under stress.
• Irrigate all cannulae to remove debris prior to sterilization. Run compressed air through cannulae after rinsing to ensure patency and dryness. Particles that run through the heat cycle of an autoclave while inside a cannula rarely come back out.

Rinse & sterilization

• Never allow delicate instruments to lie in a steel pan or tray. Lay delicate instruments on a lint-free towel or specially designed rubber or foam tray.
• Dispose of sharps appropriately. Never resterilize disposable needles.
• If packing instruments into pouches, do not pack multiple instruments together. Places where metal touches other metal will not be sterilized.
• For procedures that require multiple instruments, invest in an instrument tray. These metal or plastic boxes contain a protective silicone mat that prevents the instruments touching during storage and sterilization.
• For any instrument that could potentially pierce through a standard autoclave pouch, place a tip protector over the whole blade or jaws of the instrument.

Lubrication

• If you choose to lubricate your instruments, the lubricant needs to be approved for medical/surgical use and able to handle the high-temperature parameters of a steam autoclave.
• Lubricate instruments after every cleaning process to guard against mineral deposits and other water system impurities that may lead to stains, rust, and corrosion.
• Only antimicrobial, water-soluble lubricants are recommended to impede the growth of bacteria.

Drying

• Dry instruments thoroughly before storing. Wet or damp instruments will rust.
• A hair dryer is very effective for drying the joints and crevices of instruments quickly.
• Open hinged instruments to dry thoroughly.

Inspection prior to packaging for reuse

• Inspect hinged instruments for alignment of jaws, meshing of teeth, and stiff or cracked joints.
• Ensure that forceps meet at the tips and tines align.
• Test ring-handled instruments by holding one handle in each hand. Open the instrument and try to wiggle it. If the box lock is very loose, jaw misalignment will occur.
• Inspect scissor blades for chips. Micro-scissors should be able to cut through one thickness of surgical glove. The tips should be smooth and in alignment.
• Needle holder tips must meet, allowing the suture to be held securely. There should be no gap between the jaws. They should open and close smoothly.
• Be aware of weakened stress points. Elevated temperatures weaken these points and can actually change molecular structures of the metal. This change weakens and dulls instruments, resulting in their continual diminished performance.
• Instruments not rinsed thoroughly after chemical sterilization will stain. Do not exceed a manufacturer’s recommended soaking times.
• Thorough inspection may reveal discoloration of the metal. Some stains can be rubbed off with a rubber eraser, but it may leave a rough surface.
• Remove any faulty instrument immediately from rotation and send it for repair or repassivation. Passivation involves applying an outer layer to a material to protect it from harmful reactions such as corrosion reactions. Repassivation is repeating the process after a period of time after the protective coating disappears. Do not attempt to repair instruments yourself.

Storage

• Well-defined storage procedures reduce the chance of bent, broken and dulled instruments.
• Treat instruments gently; handle them individually or in small quantities. Masses of entangled instruments cause damage and pose a sharps risk to those handling the instruments.
• Never stack instruments on top of each other. Store instruments upright and in chronological order of sterilization.
• Reprocess and resterilize any instrument that has not been used in the last six months.

Conclusion

Proper care of ophthalmic surgical instruments not only protects our patients — it protects our investment by lengthening the instruments’ life and precludes unnecessary repairs and unwanted replacements. OP

References

1. Cox, I. (2000) Care of Ophthalmic Surgical Instruments, National Institutes of Health
2. Waldowski, L. (2017) A Growing Patient Safety Concern: Improperly Sterilized or High-Level Disinfected Equipment, The Joint Commission.
3. Johnston J. (2006) Toxic Anterior Segment Syndrome—more than sterility meets the eye. AORN J.
4. American Society of Cataract and Refractive Surgeons (2006). TASS Outbreak—Final Report.
5. American Society of Cataract and Refractive Surgery (2007). Recommended Practices for Cleaning and Sterilizing Intraocular Surgical Instruments.
6. Association for the Advancement of Medical Instrumentation (2006). Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities, ST-79.
7. Infection Control Today (2008). Providing Safe Surgical Instruments: Factors to Consider.

Lynn Girdlestone, COA, OSC, CPC is a Vision Director for the Seattle/King County Clinic and is an OSHA Certified Trainer. She also serves as a Certified Ophthalmic Assistant at Glaucoma Consultants Northwest at The Polyclinic in Seattle, WA. She has no relevant financial or non-financial relationships to disclose.