Sponsored by:
Ophthalmology Instrumentation
CIS
CIS Self-Study
Lesson Plan
(Instrument Continuing Education-ICE)
CRCST
Carla McDermott, RN, CRCST, ACE
Education Specialist,
Morton Plant Mease Healthcare
Dunedin, FL
mailbox@iahcsmm.org
Instrument Continuing Education (ICE) lessons
provide members with ongoing education in the
complex and ever-changing area of surgical instru-
ment care and handling. These lessons are designed
for CIS technicians, but can be of value to any CRCST
technician who works with surgical instrumentation.
You can use these lessons as an in-service with
your staff, or visit www.iahcsmm.org for online
grading at a nominal fee: $5 per lesson, or
bundled packages of 6 lessons for $25 (save $5)
or 12 lessons for $50 (save $10).
Each lesson plan graded online with a passing score
of 70% or higher is worth one point (contact hour).
You can use these points toward either your re-
certification of CRCST (12 points) or CIS (6 points).
Mailed submissions to IAHCSMM will not be
graded and will not be granted a point value
(paper/pencil grading of the ICE Lesson Plans
is not available through IAHCSMM or Purdue
University; IAHCSMM accepts only online
subscriptions).
LEARNING OBJECTIVES:
1. Review eye anatomy.
2. Describe five basic ophthalmic instruments.
3. Define endotoxin and their effects on ophthalmic surgeries.
4. Explain the critical need for thorough cleaning and rinsing of ophthalmic instruments.
Vision is one of our most cherished
senses. Joy, pleasure, safety and mobility
are all impacted when our ability to see is
compromised. Total loss of vision could
be devastating. People put full trust
in their eye care providers to improve
their visual capacity everyday. Dr.
Anastasios Costarides, MD, PhD, of the
Emory Eye Center in Atlanta, Georgia
says, “A successful surgical outcome
is dependent upon the coordinated
effort of staff ranging from those
who sterilize the instruments to the
surgeon performing the procedure.”
Sterile Processing professionals have
long known how critical their function
is to positive surgery outcomes and
appreciate the support of surgeons.
This lesson will focus on ophthalmic
surgical instruments and the challenges
faced by the Certified Instrument
Specialist (CIS).
Eyes are the organ that translates light
into vision. A very simple explanation
is provided to assist in understanding
the extremely complex functions of
the eye tissues. The eye ball is situated
in a recessed area of the skull which
provides some protection from exterior
trauma. Eye lids and eye lashes are also
protective elements. Conjunctival sacs
created by the eye lids help maintain the
appropriate amount of moisture over
the cornea. Muscles on the exterior
of the eyeball provide movement of
the eye to enhance our visual field.
The outer covering is called the sclera
and is fibrous tissue. The cornea is the
clear window into the eye. Immediately
behind it is the fluid filled anterior
chamber of the eye. The iris is a muscle
that is extremely sensitive to light and
helps adjust incoming light for optimal
sight. The lens helps provide focus of
image and is the portion that clouds to
become a cataract. Shape of the eye
ball is assisted by the vitreous fluid in
the posterior chamber. The retina is
the inner most layer of the eye ball and
acts as the ‘picture screen’ if you will,
for incoming images. Multiple nerve
endings through the choroid translates
this image into electrical impulses.
The optic nerve is the transmitter that
takes information we see and gets it
into the brain for interpretation. Insult
or compromise of any one of these
structures can decrease our visual
ability.
Instruments designed for ophthalmic
procedures are extremely delicate
and necessarily small. A majority of
procedures are performed with the use
of an operating microscope. Because of
this, ophthalmic instruments should be
inspected by microscope, or other high
level magnification, prior to packaging
and/or sterilization. Identification of
instruments with similar names that
are also used in other surgical services
is a challenge for everyone if they are
inadequately labeled or misplaced in
storage. For instance, a caliper used
in ophthalmology is used to accurately
measure corneal transplant grafts
and other tissues. Cardiovascular,
neurology and orthopedic services
also use a caliper. Labeling is vital to
ensure the correct ‘caliper’ gets to the
correct surgeon. A muscle hook looks
strikingly similar to a nerve hook used
by other surgical specialties. Again,

keen attention to detail and accurate
labeling is vital to smooth procedures in
surgery. Lacrimal duct probes are often
made from silver to make them easily
bendable and pliable. If an ultrasonic
cleaner is used, it is best to separate
metals, such as this, from stainless
steel to prevent damage or corrosion.
This is another instrument that can be
found in a variety of surgical services.
Eye lid retractors may also be called
eye speculum and come in a variety
of designs that may be hand held or
self retaining. Ophthalmic instrument
sets will also contain a variety of
micro-vascular needle holders.
Cataract surgeries utilize a powered
hand piece called a phacoemulsifier
used with irrigation/aspiration
handles and irrigation/aspiration tips.
Strict adherence to manufacturer
recommendations for cleaning, rinsing
and sterilization of these devices are
vital to successful surgical outcomes.
Failure to meet these specifications can
result in loss of sight. The instruments
are very delicate and do not tolerate
rough handling or being dropped.
Special sterilization containers with
protective liners are frequently utilized.
Set or tray lists are most helpful when
they are complete, kept up to date
and include manufacturer name and
catalog number. Complete information
will help ensure ophthalmic instruments
with names similar to those from other
services will remain in the ophthalmic
set.
Delicate instruments require attentive,
delicate handling. Special ultrasonic
cleaners are available for such
instruments and should be used as
directed by the instrument and ultrasonic
manufacturer. Fresh solution should be
used with each use. The ultrasonic bath
must be cleaned, disinfected and rinsed
minimally each day and preferably
after each use. Set up of solution
and ultrasonic bath should take place
immediately before use. For instance,
the unit should not be prepared for use
IAHCSMM
CIS Self-Study Lesson Plan
at 6 am when the first anticipated use it
not to occur until 9 am. The purpose of
these stringent recommendations is to
prevent accumulation of endotoxins that
can be transferred to the instruments
placed in the ultrasonic. Endotoxins
are a toxic substance produced within
some bacteria that is released when
the bacteria disintegrates. Steam
sterilization does not remove or destroy
their inflammatory capabilities which
can cause a severe reaction inside the
eye. This reaction is known as TASS,
toxic anterior segment syndrome, and
can lead to loss of vision. Additional
surgeries may also be required to
restore vision.
The American Society of Cataract and
Refractive Surgery established and
Ad Hoc Task Force on Cleaning and
Sterilization of Intraocular Instruments.
Recommended Practices for Cleaning
and Sterilizing Intraocular Surgical
Instruments was published February 16,
2007. It describes best practices that
help ensure positive patient outcomes
by eliminating as many known risk
factors as possible. The CIS is in a
unique position to assist in removal
of other substances found to cause
TASS which includes, talc from gloves,
topical ophthalmic ointments, viscous
medications, bio-burden and detergent
residue. It reiterates and affirms
information the CIS already possesses;
surgical instruments must be thoroughly
cleaned, disinfected, rinsed, dried,
packaged and sterilized. Additional
recommendations that are unique to
ophthalmic surgical instruments include
separation of ophthalmic instruments
from all other surgical instruments to
avoid contamination from cleaning
chemicals or bio-burden. Gloves
used to process these instruments
should be powder-free. Towels and
other absorbent materials should be
lint free. All detergents or solutions
used to process these instruments
should be measured accurately and
mixed with the appropriate amount
of water. Estimating either fluid can
result in increased difficulty in complete
rinsing to remove residue. Sterile
deionized rinse solutions that are free
flowing are recommended. Disposable
cleaning aids, such as brushes and
syringes should be discarded after each
use. Reusable cleaning aids should
be terminally cleaned and sterilized
according to facility policy. That
cleaning and sterilizing process should
be performed, ideally after each use,
or minimally, each day. When flushing
lumens, fresh solution is used for each
flush. Flushing within a basin, using the
same solution over and over (even on the
same instrument) is not recommended.
Final rinse of instruments in a basin is
also not recommended.
Processing ophthalmic surgical
instruments is a challenge for all
members of the surgical team from
the facility manager to the CIS. Time
and effort to be thorough, as well as
efficient, is mandatory to ensure positive
patient outcomes. The dedicated CIS
knows the critical nature of their work
and always places the patient as the top
priority.
References
International Association of Healthcare Central
Service Materiel Management. Central Service
Technical Manual. Sixth Edition. 2005.
International Association of Healthcare Central
Service Materiel Management. Instrumentation
Resource Course: Identification, Handling and
Processing of Surgical Instruments. 2006.
International Association of Healthcare Central
Service Materiel Management. Inspecting Surgical
Instruments, An Illustrated Guide. 2006.
Merriam-Webster Dictionary. Merriam-Webster, Inc.
2005.
American Society of Cataract and Refractive Surgery.
Recommended Practices for Cleaning and Sterilizing
Intraocular Surgical Instruments (online). Available
at: http://www.ascrs.org. Accessed January 9, 2008.
 CIS Self-Study Lesson Plan Quiz
(Instrument Continuing Education-ICE)
CIS
Ophthalmology Instrumentation
Questions (circle correct answer):

1. The part of the eye ball that 7. A caliper might be mislabeled and/ 13. Ultrasonic cleaners:
becomes a cataract is the: or misplaced among: a. should not be used for processing
a. cornea a. gyn instruments eye instruments
b.CRCST
choroid b. urology instruments b. can be used when instrument and
c. lens c. cardiovascular instruments cleaner manufacturer directions are
d. sclera d. dental instruments followed exactly
c. must be cleaned thoroughly once a
2. The eye ball is protected from 8. Ophthalmic tray/set lists are most week
damage by the: effective: d. have no effect, direct or indirect, on
a. skull orbit a. only for new SPD techs positive surgical outcomes
b. eye lids b. when properly maintained
c. eye lashes c. if computerized or typed 14. Working with ophthalmic
d. all the above d. for OR count sheets instruments requires:
a. lint free towels
3. The iris is a: 9. Protecting delicate instruments can b. glare free work surfaces
a. fibrous tissue involve a dedicated: c. powder free gloves
b. muscle a. specialized container d. a & c
c. ligament b. CIS
15. Aids (syringes, brushes) used for
d. part of the sclera c. work space
cleaning and rinsing ophthalmic
d. all the above
instrumentation should be:
4. Ophthalmic instruments should
be inspected: 10. Endotoxins: a. dedicated to the service
a. can not be destroyed by normal b. replaced once a month
a. by a supervisor
steam sterilization c. disposable or cleaned and sterilized
b. by the OR staff
b. are no concern in ophthalmic surgeries per facility policy
c. using magnification
c. form in the rinse basin d. soaked in gluteraldehyde at the end
d. only when needed
d. can not withstand ultrasonic of the day
5. Ophthalmic instruments: processing
a. require attentive handling
b. are easy to process 11. A severe post operative reaction in
c. need no special handling the eye is known as:
Sponsored by:
d. can be mixed with regular surgery a. POWI
instruments b. SSST
c. TASS
6. Instruments that should be d. MBFF
separated when placed in the
ultrasonic cleaner because of their 12. Accurate mixing of cleaning/
metallic make-up include: disinfecting chemicals:
a. calipers a. is critical to efficacy of product
b. muscle hooks b. effects rinsing/removal ability
c. forceps c. can positively impact a surgery outcome
d. lacrimal probes d. all the above
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