Safeguarding Your Surgical Instruments
By Rose Strong, R.N., C.O.T., C.R.N.O., Diane Roy, C.O.M.T., and Richard Ruckman, M.D.

It's been said that the right tool can make a difficult job easier. But if the right tool isn't working properly, an easy job can become difficult or even impossible. That's why proper care and handling of surgical tools is so important.

In this article, three experienced healthcare professionals share their knowledge and experience maintaining cataract and refractive surgical instruments -- information that can help you protect your patients and staff from infection and injury, while helping to eliminate unplanned surgical delays and costs.

The Care and Handling of Cataract Surgery Instruments
By Rose Strong, R.N., C.O.T., C.R.N.O.

Caring for your surgical instruments correctly is a key to minimizing complications and saving money. However, many practices follow their own protocols for care and cleaning. This can lead to instrument damage and surgical complications -- and it may nullify the warranties on your instruments. So, the first rule when caring for any surgical instrument is to know how the manufacturer recommends cleaning and handling it.

At our surgical center, in addition to following that important rule, we've developed numerous strategies that help us maximize instrument safety and effectiveness while minimizing repair and replacement costs. Here are just a few of them.

Cleaning and sterilizing

First of all, it's best to have one person do all of the cleaning. Our technician stays in the sterile area the entire work day. In my experience, this is a key to making sure that all the instruments are clean and functioning properly, which ensures that the surgeon can proceed at his or her own pace.

Here are some helpful cleaning and sterilizing strategies:

	Brace instrument tips with your finger when cleaning, and if you use a toothbrush, stroke toward the tip.

• Cleaning by hand. Support instrument tips by placing them over your index finger to brace them. (See photo.) Clean carefully. Point the tips away from you, and if you use a toothbrush, stroke toward the tip to avoid any chance of damaging the tip. If the tip is too fragile for cleaning with a toothbrush or wipe, use the ultrasonic cleaner instead.
• Ultrasonic cleaning. When cleaning fine instruments such as the diamond knife or .12 forceps, we usually hold the tips in the solution for 30 seconds and then rinse. (Note: the ultrasonic frequency must set be on low when cleaning a diamond blade.) Ultrasonic cleaning is generally used at the end of the day, after hand cleaning, although it can be used between cases if you find debris buildup on an instrument. (As always, know what your instrument manufacturers recommend.)
  • During ultrasonic cleaning, don't let the instruments come in contact with one another, or with the unprotected metal bottom of the reservoir.
  • Don't use ultrasonic cleaning to clean diamond-dusted instruments, such as a pterygium burr. Doing so may loosen or remove the diamond dust.
• Soaking. To unclog a cannula that's stopped up (or clean your cautery tip), soak in full-strength cleaning solution for 3 hours. This is also useful for removing any dried blood found on an instrument. Follow with hand washing and inspection.
• Drying. Between cases, complete drying following sterilization may not be possible, but at the end of the day, instruments must be left sterile and dry. Don't let water droplets dry on instruments; water can leave residue after it evaporates.
• Sterilizing. During sterilization instruments must be placed in the sterilizer in an open position, not touching each other, and the tray should not be overloaded. Also:
  • If you have time, warm your microsurgical instruments by setting them in the autoclave for a few minutes before you sterilize them. Otherwise, the rapid heating can create stress points -- another source of wear and tear.
  • When the sterilizing cycle is finished, condensation inside the packaging must be completely gone before the package is handled in order to maintain sterility. If you see condensation, let the instruments sit another 15 minutes to finish drying. (Generally, when sterilizing between cases, you can avoid this problem by opening the door an inch after the cycle and leaving the instruments in for 5 minutes before removing.)

Using a milk bath

Instruments should be soaked in a milk bath at least once a week, both for lubrication and to protect them against mineral deposits and system impurities that can lead to stain, rust, or corrosion. To get the most out of this process:

• Unlock and open hinges during the bath.
• Make sure instruments don't touch each other.
• How long you leave them in the bath should be determined by manufacturer's guidelines. We soak them for at least 5 hours.
• Instruments can dry with or without rinsing first.

Inspecting your instruments

Once the instruments are clean, before you begin packing them for reuse, inspect them carefully. If a microscope is available in your cleaning area, look at them under magnification. (If not, a handheld magnifier may suffice.)

Here are some specific strategies for inspecting instruments:

• Hinged instruments, such as microscissors. Make sure the jaws align and the teeth mesh together. You can see this quite clearly under the microscope.
• Ratchets. Make sure that they clamp on the first tooth. Check the ratchet by tapping it against a solid object. If it springs open, it needs repair. The clamps should close with even tension. Make sure the tips are in good alignment.
  Check the needle holder by putting the needle in and clamping down on the second tooth ratchet. The needle should stay firmly in place. If you can twist the needle when it's in the second tooth ratchet, the holder needs to be repaired.
• Ring-handle instrumentation, such as scissors. Open and wiggle them to make sure they're not loose or worn. Test their cutting ability. (Utility scissors should be able to cut through two layers of gauze; bigger scissors should cut through four layers of gauze.)
• Blades. Inspect blades for chips and protein buildup.

The role of the surgical technician

Because cleaning and inspecting are an ongoing process, your surgical technician is an important member of your team:

• As soon as the instruments are handed back to her, she should start rinsing them to remove body fluids, blood borne pathogens and bacteria. She should also inspect them carefully.
• When she puts instruments back in the tray, she should:
  • wipe them with a lint-free disposable wipe
  • make sure the tips are protected by using covers wherever appropriate and placing them with the tips facing down
  • make sure they don't touch each other.

Also, she should always put everything in the same place on the tray. This helps everyone locate instruments quickly and makes it easy to tell when an instrument is missing.

Cleaning strategies

Here's some advice for cleaning specific instruments:

• Cannulas. Cannulas can easily become stopped up. To prevent this, flush them with fluid and air after each use.
• When a cannula does become stopped up, soak it in full strength instrument cleaner overnight. Then, flush the cannula with 15 cc of sterile or distilled water and back-flush it with 3 cc of sterile or distilled water. Next, blow 30 to 60 cc of air through it in 4 or 5 bursts, to dry the inside of it. Finally, make sure you rinse the tip to remove any material that might be clinging to it. Finally, sterilize. (If you can't remove whatever is plugging the cannula, replace it.)
  • Note: Don't run the sterilizer for one cannula. Instead, let it soak 20 to 25 minutes in alcohol before you package it.
• Phaco handpiece. Clean the tip and phaco handpiece separately, as described in your manufacturer's guidelines. Generally, you should flush the handpiece with sterile distilled water and air, then check for debris.
  • Next, make sure that you disassemble the handpiece before you sterilize it. Take your tips off and lay them out separately. (Don't stack them.)
  • The phaco handpiece should have its own tray for sterilizing. I recommend that you use a plastic tray, not a metal tray, to avoid reactions between the metals.
• Irrigation and aspiration tips. Flush tips with distilled water and blow dry with air. Use the amount of water and air specified in your manufacturer's guidelines. Inspect; then sterilize.
• Phaco tubing. Remove, irrigate and blow dry using the amount of air and distilled water specified in your manufacturer guidelines. (We buy multiuse tubing, as opposed to "single-use." We have 30 sets, so we can use one set per case. We use each set of tubing at least 20 times before discarding.)
  We purchased the Quick Rinse System, which allows us to clean all of our tubing sets quickly at the end of the day. Once clean, we put them in the autoclave and run them through a 4-minute cycle with a 3-minute drying time. Finally, we package them and sterilize them using the wrapped cycle.

Overall guidelines

In addition to following your manufacturers' guidelines, the following strategies will do a lot to help you maintain your instruments:

• Create established guidelines that dictate everything you and your staff need to know and do to handle instrumentation properly. All procedures and processes for washing, drying, inspecting, lubricating and sterilizing your instruments should be written down. Routines should be memorized and followed to the letter.
• Remember that everyone handling used instruments must wear gloves, mask and goggles until the first sterilization cycle is complete, for their own protection.
• Make sure your technicians never, ever allow your instruments to dry when they haven't been cleaned, to prevent endotoxins from building up on them.
• Make sure that the technicians who manage these tasks for you are well-trained and experienced.

Rose Strong, R.N., C.O.T., C.R.N.O., has 18 years' experience in ophthalmology and 30 years' experience as a nurse. She is currently director of nursing at the Heights Eye Surgery Center in Houston. She's actively involved with annual meeting planning for the American Society of Ophthalmic Registered Nurses (ASORN) and is a speaker for ASORN and the American Society of Cataract and Refractive Surgery.

The Care and Handling of Refractive Surgery Instruments
By Diane Roy, C.O.M.T.

Needless to say, refractive surgery instruments are expensive, and their condition can determine a patient's outcome. It's important that we treat them with respect. Here are some helpful strategies to follow when caring for these instruments.

• Cleaning instruments between cases. Remember that sterilizing isn't the same as cleaning. If you haven't cleaned your instruments, you'll just sterilize the debris that's left on them.
  We take the following steps to minimize the danger of contamination:
  • As soon as you finish using an instrument, place it in a bowl containing sterile, distilled water about an inch deep. This will keep any debris from drying and becoming caked onto the surfaces. (Never allow blood, tissue, or saline to dry on your instruments.)
  • After each surgery, move instruments to a designated cleaning area.
    We use three bowls for cleaning. The first bowl contains sterile distilled water with one or two drops of detergent. (If you use more than a minimal amount of detergent you may get too much sudsing.) The next two bowls contain sterile, distilled water for rinsing.
    Gently scrub the instruments using a soft bristle toothbrush in the mild soap solution. Pay special attention to areas that have touched the cornea. Then rinse the instruments thoroughly in the two rinsing bowls and lay them on a lint-free cloth to dry. (Note: Never use balanced salt solution as a rinse.)
  • During the cleaning process, inspect the instruments carefully:
    • Check for any remaining debris. (If you find anything, clean and rinse the instruments again.)
    • Look for nicks.
    • Check to see that parts are in good alignment. Forceps and scissors tips should not be bent, and forceps should grab effectively.
    • Make sure that angles of cannulas are correct.

  If anything is broken, nicked or out of alignment, send the instrument out to be repaired.

  	Sterilizer Upkeep
  	To care for your instruments, you have to begin by caring for your sterilizer. In our office we use a Statim 5000 and a Statim 2000. Here's the weekly maintenance system that we've developed: - Every Friday, drain all the water from the reservoir and put in about a half a bottle of 70% isopropyl alcohol. Then take a brush and scrub as many surfaces as you're able to reach. - Next, drain the alcohol out and fill the reservoir with boiling distilled water. - After letting the boiling distilled water sit for 20 minutes, drain the water and let the sterilizer air dry over the weekend. - On Monday morning, fill the reservoir with sterile, distilled water and run one cycle before sterilizing any instruments.

• Sterilization. To ensure effective sterilization:
  • Before sterilizing everything at the beginning of the day, always inspect your instruments to make sure no debris is left from the last time they were used.
  • Place the instruments on the tray so that they don't touch each other -- or the sides of the tray. Any sharp tips should be facing down into the nubbins. (Use protective tips if necessary.)
  • Preoperatively, run instruments through the long, heavy duty cycle. (Our sterilizer runs 6 minutes at 132° Celsius).
  •  Only use sterile distilled water in the reservoir (not plain).
  •  Between cases, use the short sterilization cycle. (Our Statim 2000 has a short cycle of 3 and a half minutes at 132°.)
  • Postoperatively, clean all instruments. (We use a syringe to inject sterile distilled water through the suction tubing.) Then sterilize everything using the heavy duty cycle again.
• Drying. Allow your instruments to air dry at the end of the day. If the instruments aren't completely dry before you store them, they'll become corroded and rusty. Also, fluid left on an instrument can provide a medium for bacteria.
  If I have enough time I leave our instruments in the Statim set for the complete drying cycle. If not, I leave the instruments out in the open with the tray tipped up a little so that all the moisture drains out. The next morning, I inspect everything to make sure the instruments are completely dry.
  As an alternative, you can dry the instruments at the end of the day with a lint-free cloth or a sterile hot air blower, if one is available. (Some practices use microfiltered canned air for this purpose.)
• Other suggestions. To avoid potential problems during cleaning and sterilization:
  • Never put your tonometer in the sterilizer -- it will become cloudy. Instead, clean it with 70% isopropyl alcohol.
  • Never use metal brushes or abrasive powders to clean your instruments.
  • If you reuse cannulas, pay special attention to them when you're cleaning. We squirt a mild soap solution through the cannula using a syringe; then we use the same method to rinse with sterile distilled water. Finally, we squirt a syringe full of air through them and set them on their ends to air dry until we're ready to sterilize them.

Caring for your microkeratome

Microkeratomes have many parts; some are autoclavable and some aren't.

• Parts that are autoclavable -- such as suction rings, the blade holder and the suction tubing -- should be cleaned with the detergent solution, rinsed and autoclaved at 132° Celsius.
  We sterilize our suction tubing at the beginning and at the end of each day. Between cases we just clean the outside of the tubing with alcohol.
• Parts that can't be autoclaved -- in the case of our Nidek microkeratome, this would include the handpiece, the connecting cable, a flap diameter checker and tonometer -- should be cleaned and disinfected with ethylene oxide gas or 70% sterile isopropyl alcohol.
• Some parts, such as the control box, foot pedal and power cord, don't need to be sterilized. These can be cleaned with gauze dampened with a detergent, followed by gauze dampened with plain water, and then allowed to air dry.

Before operating

Preoperatively, inspect all autoclavable parts for any debris; if necessary, clean them. Sterilize these parts, following the standards defined by your medical facility.

Ideally, your instruments should dry completely before use. If turnover time is too short for the instruments to dry completely, dry them as much as possible. Use a merocel for this purpose, or let them drain dry.

Parts that you're not able to autoclave -- those that you clean with 70% sterile isopropyl alcohol -- MUST be allowed to air dry, because alcohol can damage the corneal epithelium.

Between cases

Between cases, immediately disassemble your microkeratome. If your sterilization area is in another room, set the sterilizable parts in a small bowl of sterile distilled water so debris won't be able to dry onto them.

During cleaning, pay special attention to accessories that contact the cornea, such as the suction ring, blade holder and marker. Immerse these in your mild soap solution. Use a soft-bristle toothbrush to scrub any areas where fluid or debris can collect; then rinse in your two sterile distilled water rinses.

• When cleaning the suction ring, take a 10-cc syringe filled with a soap solution and squirt that through each one of the ports where the suction tubing connects. Do the same thing with sterile water to rinse. Finally, use the syringe to squirt air through the ports to get all the fluid out.
• After cleaning the microkeratome head (with the soapy solution and toothbrush), we don't use canned air for drying. Instead we take a merocel and insert it into any areas where fluid can collect. Then we use the short sterilization cycle.
  After cleaning the head, we check parts (such as the micron depth head and blade holder on our Nidek microkeratome) for scratches or nicks. (We also tilt the micron depth head to make sure the oscillation slider moves smoothly.)
• Accessories that don't contact the cornea, like wrenches, can be cleaned in the soapy solution, rinsed and autoclaved.
• Use alcohol to clean parts that can't be autoclaved. (We put a sterile drape over the top of the control unit, and place these parts on the drape as we clean them between cases. )

Postoperatively

Follow the previous steps, but use the heavy duty sterilization cycle. Also:

• Dry instruments and instrument trays completely at the end of the day.
• Sterilize your tubing at the beginning and end of the day.
• Wipe down the unit with alcohol or a mild soap solution.
• Use the soap solution to scrub out all three cleaning bowls and then do a sterile water rinse, followed by a rinse with alcohol and air drying. (Or, use new bowls each day.)

A few final thoughts

In general, try to follow these three principles:

• Don't learn proper care methods the hard way. Read your manuals so you know what your manufacturer recommends, and find out what your facility and doctors recommend.
• Set up a routine so that everybody in your office is cleaning and caring for instruments in the same manner.
• Always treat your instruments with tender, loving care.

Diane Roy, C.O.M.T., is refractive surgery coordinator with Bonner & Buntrock Eye Clinic. She's worked in ophthalmology for 15 years.

The Care and Handling of a Diamond Blade
By Richard Ruchman, M.D.

As you know, diamond knives can be expensive, especially in a hospital situation where the diamond may be damaged almost every day. However, with proper care, diamond knives are cost-effective -- especially if you do more than 200 cases a year. We estimate that our practice has saved more than $95,000 over the past 5 years by using diamond blades instead of single-use metal blades.

Here, I'd like to offer some suggestions for effective care of diamond blades, based on our experience.

Keeping the blade clean

Back in the days when we first started using diamond blades for radial keratotomy (RK), we took the diamond blade and shoved it into a little peanut or a little 4 by 4 to clean it at the end of the case. This is the wrong thing to do -- it's guaranteed to damage the blade! In fact, the blade must never touch anything except tissue and fluids.

	A diamond blade with a buildup of protein debris (like the one on the right) has lost its ability to cut tissue.

To clean the blade:

• Thoroughly rinse the diamond blade with distilled water immediately after each use, taking care not to touch the diamond with anything other than fluid.
• Fill your ultrasound unit with an ammoniated jewelry cleaner. With the diamond blade extended from the handle, submerge it into the ultrasound unit for at least 30 seconds. Important note: The unit must run at low ultrasonic power. If you run it at high power, the edge of the blade will be damaged.
  Remember to check your manual; your manufacturer may have specific suggestions for ultrasonic cleaning.
• After the ultrasonic cleaning, remove any residual cleaner using distilled water. Our technicians use a squirt bottle so the water has enough force to dislodge debris.
• The next step is very important: Use a steam cleaner. This instrument generates a forceful jet of steam that removes a lot of residual protein from the blade. (Once sterilized, protein remaining on the blade can be difficult to remove.) Protein buildup will compromise the blade's cutting ability.
• Follow standard disinfection and sterilization procedures.

Other suggestions

Here are a few more ways to minimize costs associated with diamond blades. (Note: Check for manufacturer suggestions.)

• We make one person responsible for blade care. She makes sure the blade is sterilized between cases and put back in its case. We've only had one broken diamond in 5 years -- and that was when she had a day off! (Pay this person well -- he or she will save you a bundle.)
• At the start of surgery, the blade should remain in the case until used. Your technician should hand it to you with the blade retracted into its protective casing. Only the surgeon should extend it. Once extended, it should only touch tissue.
• Invest in a steam cleaner. This has been one of the best investments our ASC has ever made. It's saved the life of our diamond blades -- and any number of other instruments.
• Inspect the diamond blade periodically under a microscope, looking for protein debris. (See picture) Once a blade gets as bad as the blade on the right, it's less effective than a dull metal blade. (An old RK microscope will provide high magnification for this purpose.)
• Send your blades out for rehoning about once a year. (We spend about $1,000 a year on this kind of maintenance.)
• Establish your protocol for handling and cleaning of the blade, and never allow shortcuts!

Dr. Ruckman is president and medical director of The Center for Sight in Lufkin, Texas. He specializes in cataract and refractive surgery. He's been in practice since 1978; he opened his ASC in 1991.