Ophthalmic Surgical Instruments

Rajesh Sinha MD DNB FIACLE FRCS Professor Cornea, Lens and Refractive Surgery Services Dr Rajendra Prasad Centre for Ophthalmic Sciences All India Institute of Medial Sciences New Delhi, India

Jeewan S Titiyal MD Padma Shri Awardee Professor and Head Cornea, Cataract and Refractive Surgery Services Dr Rajendra Prasad Centre for Ophthalmic Sciences All India Institute of Medical Sciences New Delhi,Brothers India

Vijay Kumar Sharma MS Consultant Advanced Centre for Ophthalmic and Visual Sciences Army Hospital Research and Referral New Delhi, India

Foreword JaypeeAmar Agarwal

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Prlimes-Rajesh Sinha.indd 3 18-Feb-17 3:35:43 PM Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: [email protected]

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Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2017, Jaypee Brothers Medical Publishers The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book. Brothers All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought. Every Jaypeeeffort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. Inquiries for bulk sales may be solicited at: [email protected] Ophthalmic Surgical Instruments

First Edition: 2017

ISBN 978-93-86322-97-5

Printed at

Prlimes-Rajesh Sinha.indd 4 18-Feb-17 3:35:43 PM Dedicated to The three special women in my life, My mother, Malti, for her care and blessings, My wife, Renu, for her support and My daughter, Suhani, for her loving smile — Rajesh Sinha My wife, Mrs Basanti Titiyal, My children, Dr Hemant Titiyal and Dr Renuka Titiyal — Jeewan S Titiyal My wife, Dr ManishaBrothers My daughter, Naisha —Vijay Kumar Sharma

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Prlimes-Rajesh Sinha.indd 5 18-Feb-17 3:35:43 PM Contributors

Chintan J Dedhia Neha Kamble Fellow Senior Resident Vitreoretinal Services Dr Rajendra Prasad Centre for LV Prasad Eye Institute Ophthalmic Sciences Hyderabad, Telangana, India All India Institute of Medial Sciences New Delhi, India Dewang Angmo Assistant Professor Nitin Vichare Dr Rajendra Prasad Centre for Classified Specialist Ophthalmic Sciences Command Hospital (Central All India Institute of Medical Command) Sciences Lucknow, Uttar Pradesh, India New Delhi, India Rajesh Sinha Digvijay Singh Professor Consultant Cornea, Lens and Refractive Surgery Medanta – The Medicity ServicesBrothers Gurugram, Haryana, India Dr Rajendra Prasad Centre for Ophthalmic Sciences Jeewan S Titiyal All India Institute of Medial Padma Shri Awardee Sciences Professor and Head New Delhi, India Cornea, Cataract and Refractive Surgery Services Ravi Bypareddy Dr Rajendra Prasad Centre for Assistant Professor Ophthalmic Sciences Minto Ophthalmic Hospital All India Institute of Medical Bangalore Medical College and Sciences Research Institute NewJaypee Delhi, India Bengaluru, Karnataka, India Manpreet Kaur Reena K Singh Senior Resident Senior Resident Dr Rajendra Prasad Centre for Dr Rajendra Prasad Centre for Ophthalmic Sciences Ophthalmic Sciences All India Institute of Medical All India Institute of Medial Sciences Sciences New Delhi, India New Delhi, India

Prlimes-Rajesh Sinha.indd 7 18-Feb-17 3:35:43 PM viii Ophthalmic Surgical Instruments Rohan Chawla Supriya Arora Assistant Professor Consultant Vitreoretinal Services Eye Care Centre Dr Rajendra Prasad Centre for Princess Margaret Hospital Ophthalmic Sciences Nassau, New Providence, Bahamas All India Institute of Medial Sciences New Delhi, India Tarun Arora Consultant Rohit Saxena Eye Care Centre Professor Princess Margaret Hospital Dr Rajendra Prasad Centre for Nassau, New Providence, Bahamas Ophthalmic Sciences All India Institute of Medial Sciences Vijay Kumar Sharma New Delhi, India Consultant Advanced Centre for Ophthalmic Roshan T and Visual Sciences Fellow Army Hospital Research and Narayana Nethralaya Referral Bengaluru, Karnataka, India New Delhi, India Sandeep Gupta Reader Armed Forces Medical College Pune, Maharashtra, India Brothers

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Prlimes-Rajesh Sinha.indd 8 18-Feb-17 3:35:43 PM Foreword

Dr Rajesh Sinha, Professor of Ophthalmology in Cornea, Lens and Refractive Surgery Services at Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India; Dr Jeewan S Titiyal, Professor and Head of the Cornea, Cataract and Refractive Surgery Services at Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, and Dr (Lt Col) Vijay Kumar Sharma, an alumnus of the prestigious Armed Forces Medical College (AFMC), Pune, Maharashtra, India are to be congratulated for attempting and accomplishing the almost impossible task of assembling in one place the various surgical instruments used in modern ophthalmic surgery with the help of systematically arranged photographs. Making the information correct and complete is winning only half the battle; the other half is using a format that helps students assimilate and apply it. The book with the help of a broad range of photographs laid out in a rational and effectiveBrothers fashion, resulting in a creative and unique atlas, is suitable for all levels of eye-care professionals, students in training, residents in ophthalmology as well as budding practitioners. It is an honor for me to be invited to write the foreword for this book, which was compiled by my esteemed colleague, Dr Rajesh Sinha, has 324 publications to his name; 127 are in indexed journals; 77 chapters in various textbooks and two textbooks and 4 educational books and manuals. He has received various awards and orations and when I saw him doing live surgery once I was just gasping at his surgical skill. Dr Jeewan S Titiyal is the first Indian to perform live surgery demonstration in ASCRS, USA. Dr (Lt Col) Vijay Kumar Sharma is ConsultantJaypee at Army Hospital Research and Referral, New Delhi and is involved in teaching postgraduate and undergraduate students. They have my congratulations and admiration for a thoughtful and handsome job well done. Amar Agarwal MS FRCS FRCOphthal Chairman Dr Agarwal’s Group of Eye Hospitals Dr Agarwal’s Eye Hospital and Eye Research Centre Chennai, Tamil Nadu, India Email: [email protected]

Prlimes-Rajesh Sinha.indd 9 18-Feb-17 3:35:43 PM Preface

Ophthalmic surgery is evolving at a rapid pace with the introduction of newer techniques and technology. Various newer surgical instruments are being added to the ever-expanding kit of the ophthalmologists. Most of the postgraduate and undergraduate students do not have access to the newer surgical instruments and find it difficult to answer the questions related to these newer instruments in the examinations. There is no dedicated book on the surgical instruments at present, and this topic is simply discussed in the last few pages of some of the ophthalmology textbooks with inadequate photographs and description about the instruments. We felt that there is need of a book which exclusively deals with the instruments used in ophthalmic surgery with description about their specifications and uses so that postgraduates, fellows and general ophthalmologists can learn about the finer aspects and uses of these instruments. This book provides comprehensive description and colored photographs about the instrumentsBrothers used in various ophthalmic surgeries, including those being used in cornea and refractive surgery, retinal surgeries, squint and oculoplastic surgeries, glaucoma surgery, cataract and femtocataract surgery as well as sterilization techniques of these instruments. Each chapter is devoted to surgical instruments used in a particular subspecialty of ophthalmology. Original photographs of good quality with a similar background in majority of the chapters have been used not only to maintain a uniformity but also to provide crisp visuals of each instrument. This book will not only help the undergraduate and postgraduate students but also the young practitioners who are planning to establish their own set-up, as they get Jaypeea sort of checklist for the instruments that they have to purchase as well as an accurate information about their exact uses. Despite our best efforts, the book may have some inaccuracies. Feedback from teachers and students are most welcomed and will help in the improvement of the book in the future. We sincerely hope that this book will be of immense help and useful guide for the residents, fellows and general ophthalmologists alike. Rajesh Sinha Jeewan S Titiyal Vijay Kumar Sharma

Prlimes-Rajesh Sinha.indd 11 18-Feb-17 3:35:43 PM Contents

1. Basic Instruments in Ophthalmic Surgery 1 Sandeep Gupta, Vijay K Sharma • Lid Speculums 1 • Forceps 2 • Eye Scissors 5 • Needle Holder 7 • Callipers 8 • Instrument Box 9 2. Instruments for Cataract Surgery 10 Manpreet Kaur, Roshan T, Jeewan S Titiyal • Thermal Ball Point Cautery 10 • Electrocautery 10 • Bard Parker Knife Handle with Blade 11 • Microvitreoretinal Blade 12 • Side Port/Stab Knives 13 • Crescent Knife 13 Brothers • Keratome 14 • Cystotome 14 • Microcapsulorhexis Forceps 15 • Smith Lens Expressor (Lens Hook) 15 • Wire Vectis 16 • McIntyre Irrigating Wire Vectis 16 • Simcoe Irrigation–Aspiration Cannula 17 • J-shaped Double Irrigation–Aspiration Cannula 18 • Sinskey Hook 18 • Chopper 19 • Phacoemulsification Probe and Tips 20 • Infusion Sleeves 21 •Jaypee Iris Repositor 22 • Coaxial Irrigation–Aspiration Handpiece 22 • Bimanual Irrigation–Aspiration Handpiece 23 • Cannula 23 • Anterior Chamber Maintainer 24 • Von Graefe Knife 24 • Arruga Capsule Forceps 25 • Kirby Lens Expressor and Repository 25 • Kirby Lens Expressor and Vectis 26

Prlimes-Rajesh Sinha.indd 13 18-Feb-17 3:35:43 PM xiv Ophthalmic Surgical Instruments • Lens Holding Forceps 26 • Lens Folding Forceps 26 • IOL Injector 26 • Autosert 27 • Stevens Femtosecond Flap Lifter 28 • Krokchings Femto Incision Opening Spatula 28 • Cionni Femto Spatula and Nucleus Divider 28 • Dr Rana’s Double Tooth Phaco Chopper 29 3. Instruments Used in Refractive Surgery 31 Tarun Arora, Rajesh Sinha, Jeewan S Titiyal • Various Instruments Used in Cornea-based Refractive Surgery 31 • Instruments Used for Implantable Collamer Lens Based Surgery 35 • Instruments for Femtosecond Assisted Intacs 36 4. Instruments for Corneal Surgeries and Eye Banking 38 Reena K Singh, Rajesh Sinha, Jeewan S Titiyal • Instruments Used for Eye/Corneoscleral Button Retrieval 39 • Specular Microscopy in Eye Bank 43 Corneal Surgery Instruments 44 • Different Types of Speculum 44 • Superior Rrectus Fixation Forceps 45 • Flieringa Scleral Fixation Rings Brothers45 • Scale 46 • Castroviejo Calliper 46 • Radial Keratotomy Marker 47 • Teflon Corneal Blocks 47 • King’s Clamp 48 • Razor Blade Breaker and Holder 48 • Diamond Knife 49 • Hand-held Corneal Trephines 49 Microlamellar Dissectors 50 • Devers-Terry Straight and Curved Lamellar Dissectors 50 • Gill’s Lamellar Dissector 50 •Jaypee Tooke’s Knife 51 • Cyclodialysis Spatula 51 • Flap Lifter double-ended 51 • DSAEK Spatula 52 • Reverse Sinskey Hook 52 • Miniperforated Spoon/Graft Shifter 52 • Ogawa DSAEK Graft Holding Forceps 53 • Busin Glide 53

Prlimes-Rajesh Sinha.indd 14 18-Feb-17 3:35:44 PM Contents xv • DSAEK Busin Forceps 54 • Small Incision Manipulating Forceps 54 • Moria Lamellar System for Keratoplasty 54 5. Instruments for Strabismus Surgery 57 Rohit Saxena, Digvijay Singh • Speculum 57 • Scissors 59 • Needle Holder 61 • Caliper 62 • Blade Holders 63 • Forceps 63 • Muscle Hooks 65 • Muscle Clamps 69 • Retractors 70 • Miscellaneous Instruments 71 6. Instruments Used in Oculoplasty Surgeries 73 Nitin Vichare • Forceps 73 • Scissors 75 • Retractors 77 • Needle Holders 80 • Lid Spatula (Eye Guard) 81 • Nettleship’s Punctal Dilator 82 Brothers • Bowman Probes 82 • Caliper 83 • Kerrison Rongeurs (Bone Punch) 84 • Lacrimal Sac Dissector and Curette 85 • Freer Periosteal Elevator 85 • Chisel and Hammer 86 • Ptosis Muscle Clamp 86 • Entropin Clamp 87 • Wright Facia Needle 87 • Enucleation Spoon 88 •Jaypee Evisceration Scoop 88 7. Instruments for Glaucoma Surgeries 89 Dewang Angmo, Neha Kamble • Crescent Blade (Sclerocorneal Splitter) 89 • Razor Blade Fragment with Blade Holder 89 • Westcott’s Spring Scissors 90 • Vannas Scissors 91 • DeWecker Iris Scissors 91 • Kelly Descemet’s Membrane Punch 92

Prlimes-Rajesh Sinha.indd 15 18-Feb-17 3:35:44 PM xvi Ophthalmic Surgical Instruments • Harms Trabeculotomy Probe 93 • Glaucolight-illuminated Fiberoptic Microcatheter 93 • Cyclodialysis Spatula 94 • Surgical Super Absorbent Spears/Sponges 95 • Biodegradable Collagen Matrix 95 • Ahmed Glaucoma Valve Tube Insertion Forceps 97 • Surgical Goniolenses 97 • Glaucoma Drainage Devices 99 8. Instruments Used in Vitreoretinal Surgeries 101 Ravi Bypareddy, Chintan J Dedhia, Rohan Chawla • Instruments Used in Scleral Buckling Surgery 101 • Instruments Used in Vitreoretinal Surgery 104 9. Needles and Sutures in Ophthalmology 121 Tarun Arora, Supriya Arora, Rajesh Sinha, Jeewan S Titiyal • Needles 121 • Sutures 125 10. Sterilization of Surgical Instruments 132 Manpreet Kaur, Roshan T, Rajesh Sinha, Jeewan S Titiyal • Cleaning of Instruments and Equipment 133 • Inspection 135 • Packaging 135 • Sterilization 136 Brothers • Sterile Storage 143 • Quality Assurance 143 Index 147

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Prlimes-Rajesh Sinha.indd 16 18-Feb-17 3:35:44 PM 3 Chapter

Instruments Used in Refractive Surgery

Tarun Arora, Rajesh Sinha, Jeewan S Titiyal

INTRODUCTION Refractive eye surgery is any eye surgery used to improve the refractive state of the eye and decrease or eliminate dependency on glasses or contact lenses. This can include various methods of surgical remodeling of the cornea or implanting intraocular lenses with or without cataract surgery. Brothers

VARIOUS INSTRUMENTS USED IN CORNEA-BASED REFRACTIVE SURGERY Lieberman Temporal Speculum An appropriate speculum must be selected to provide adequate exposure of the globe for placement of the microkeratome vacuum ring. Most surgeons prefer the adjustable Lieberman speculum that retracts the lids sufficiently to provide unobstructed access for the Jaypeemicrokeratome. Several models are available with and without aspiration. It is a temporal speculum with Kratz-style open wire blades along with adjustable mechanism resting on nasal bridge (Figure 1).

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Figure 1: Lieberman self-retaining speculum

SoftFitTM Patient Interface It is a one-piece design of the LenSx® Laser’s SoftFitTM Patient Interface and connects to the counter-balanced, floating laser objective head (Figure 2).

Brothers Figure 2: Patient interface The interface produces a 66% reduction in laser energy, along with an IOP rise of only 16 mm Hg above baseline. Additionally, the exclusive hydrogel lens technology of the patient interface is designed to: • Minimize corneal distortion compared to solid interfaces • Reduce intraocular pressure to the cornea compared with solid interfaces • Fixate the eye, enhancing control of movement compared to liquidJaypee interfaces. LASIK Flap Marker Corneal markers are designed to place identifying patterns on the cornea. A single round marker is commonly used to facilitate the centration of the microkeratome vacuum ring. Various markers with asymmetrical rings are available to provide landmarks for realignment of the flap and for identifying the epithelial side of a loose flap (Figure 3).

CH-03.indd 32 18-Feb-17 3:35:22 PM Instruments Used in Refractive Surgery 33

Figure 3: LASIK flap marker

FemtoLASIK Flap Spatula Double Ended Specific instruments have been designed for handling the flap. This can be done with a spatula or a forcep. Spatulas typically have a beveled front edge, to easily enter the flap interface, and smoothly rounded surface to elevate and reposit the flap. They are double- ended instrument to unstick and lift the corneal flap in LASIK procedures. The delicate hook works at the flap edges inside the groove. The ”C” shaped tapered loop, once positioned below the flap, and lifts it with a gentle push on the horizontal plane; from the hinge to the exit point (Figure 4). Brothers

Figure 4: FemtoLASIK flap spatula double ended

Flap Protectors These shield the corneal flap during excimer laser ablation. They have a dull finish to minimize reflections. Various models are available to protectJaypee either nasally or superiorly hinged flap (Figure 5).

Figure 5: LASIK flap protecor

CH-03.indd 33 18-Feb-17 3:35:23 PM 34 Ophthalmic Surgical Instruments LASIK Irrigation Cannula Cannulas are used for irrigating the eye before and after reposition of flap. They are designed to enter the interface with ease and are available in various models with single or multiple ports. It has a fluted-front opening, slightly curved, port that is 26 gauge and is 12 mm in length from angle to tip (Figure 6).

Figure 6: LASIK irrigation cannula

Hockey Epithelium Removal Knife Hockey knife can be used to remove epithelium during PRK procedures and during LASIK retreatment. It has a round handle with approximately 130 mm of lengthBrothers (Figure 7).

Figure 7: Hockey epithelium removal knife

Camellin-style LASEK Trephine 8.0 mm and 9.0 mm It is a double-ended trephine with 8.0 mm and 9.0 mm diameter trephinesJaypee on either side of a flat handle (Figure 8).

Figure 8: Camellin-style LASEK trephine

CH-03.indd 34 18-Feb-17 3:35:23 PM Instruments Used in Refractive Surgery 35 INSTRUMENTS USED FOR IMPLANTABLE COLLAMER LENS (ICLTM) BASED SURGERY (FIGURE 9)

Figure 9: Instruments for ICLTM surgery

Coaxial Forceps for ICL™ Lens Loading, Angled Tips This forcep is designed to assist in the correct positioning of the ICL near the injector tip before insertion. It is a 20-gauge retinal-style instrument that features special jaws with a series of convex and concave surfaces for grasping the lensBrothers without damaging the optics (Figure 10).

Jaypee TM Figure 10: Coaxial forceps for ICL lens loading, angled tips

Spatula for ICLTM This spatula is designed to aid in the proper placement of an ICL. After the lens has been inserted, the finely textured, micro-ring tips are used to position the haptic into the sulcus (Figure 11).

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Figure 11: ICL spatula

INSTRUMENTS FOR FEMTOSECOND ASSISTED INTACS Intacs Pocketing Hook Made up of titanium, pocketing hook initiates the delamination at the base of the incision by applying a slight amount of tension to the corneal tissue (Figure 12). Brothers

Figure 12: Intacs pocketing hook

Intacs Glide Blade Handle with Symmetric Glide Stainless steel handle that has been specifically designed so as to be used with the detachable symmetric glide (Figure 13). The bifurcated glide instrument is also made up of stainless steel, and is inserted intoJaypee entry incisions to initiate the stromal pocket dissection.

A B Figures 13A and B: Intacs glide blade handle with symmetric glide

CH-03.indd 36 18-Feb-17 3:35:24 PM Instruments Used in Refractive Surgery 37 Intacs Forceps The forceps is made of titanium and has notched tips that match the shape of Intacs segment (Figure 14). It felicitates easy removal of the segment from the carrier. It uses the same geometric arc action of the tunnel dissector to insert the Intacs in the stromal pocket. The forceps are designed so that they can be used with either hand.

A B Figures 14A and B: Intacs forceps

Intacs Corneal Separator The separator is made up of titanium and used to dissect the stromal tunnel before insertion of the Intacs is commenced. They are available as a set to be used for eitherBrothers channel (Figure 15).

A B Figures 15A and B: Intacs corneal separator ZoneJaypee Marker Made up of titanium, zone marker with cross hairs is used to mark the geometric center of the cornea (Figure 16).

Figure 16: Zone marker

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