CIS SELF-STUDY LESSON PLAN Lesson No. CIS 272 (Instrument Continuing Education - ICE) Sponsored by:

Ophthalmic Surgical Instruments

BY JON WOOD, BAAS, CIS, CRCST, CLINICAL EDUCATOR, IAHCSMM

Instrument Continuing Education (ICE) lessons provide members with ongoing education in the complex and ever-changing area of surgical LEARNING OBJECTIVES instrument care and handling. These lessons are 1. Identify common eye instruments used during an eye muscle procedure designed for CIS technicians, but can be of value 2. Review toxic anterior segment syndrome and ways to avoid the postoperative to any CRCST technician who works with surgical inflammatory reaction instrumentation. 3. Discuss the function of eye instrumentation during an eye muscle procedure

Earn Continuing Education Credits:

Online: Visit www.iahcsmm.org for online grading at a nominal fee. he success of every Central Objective 1: Identify common eye By mail: For written grading of individual lessons, Service/Sterile Processing instruments used during eye muscle send completed quiz and $15 to: (CS/SP) department and, procedures Purdue University - Online Learning ultimately, the success of every Instrumentation can differ from Ernest C. Young Hall, Room 526 155 S. Grant Street Tprocedure performed in surgery, depends healthcare facility to healthcare facility West Lafayette, IN 47907 on the quality of the instruments and is generally selected based upon the provided. Ensuring each surgical surgeon’s specific procedure needs and Scoring: Each quiz graded online at www.iahcsmm.org or through Purdue University, procedure has functional instruments preferences. The following is a list of with a passing score is worth two points (2 contact available and instrument sets that are common eye muscle instrumentation: hours) toward your CIS re-certification (6 points) correct, complete and ready for use when or CRCST re-certification (12 points). needed is an essential, yet challenging Basic Eye muscle set More information: IAHCSMM provides online responsibility. This lesson will identify • Jameson muscle hook grading service for any of the Lesson Plan commonly-used instruments found in • Graefe Strabismus hook (See Figure 1) varieties. Purdue University provides grading services solely for CRCST and CIS lessons. Direct ophthalmic surgery, review steps to avoid • Stevens tenotomy hook any questions about online grading to IAHCSMM toxic anterior segment syndrome (TASS) • Manson double-ended strabismus hook at 312.440.0078. Questions about written and explain how ophthalmic instruments • Desmarres lid retractor grading are answered by Purdue University at 800.830.0269. are used during eye muscle procedures. • Bishop-Harmon tissue forceps

Check for Be sure the screw cleanliness intact, area debris free, and function no stress fractures

Check tips Ensure screw is in place, area is debris free

Figure 1: Graefe Strabismus Hook Figure 2: Castroviejo Caliper CIS SELF-STUDY LESSON PLAN

Check for cleanliness. Be sure wire is intact.

Figure 3: Vannas Scissors Figure 4: Wire Eye Speculums: Barraquer Wire (Left) and Solid Eye Speculum (Right)

• Castroviejo fixation forceps (0.3mm or reactions with enzymatic and detergent transferred to the patient. According to 0.5mm) solutions, residuals from viscoelastic the Association for the Advancement • Moody locking forceps materials and cross-contamination of of Medical Instrumentation (AAMI), • Castroviejo caliper (See Figure 2) instrumentation from other services. eye instruments, especially intraocular • Vannas scissors (See Figure 3) As with any instrument being sterilized, instruments, should be processed • Westcott curved tenotomy scissors all sterilization parameters must be separately from other instruments. • Troutman-Castroviejo corneal section monitored closely to ensure the physical, This separation reduces the potential scissors chemical and biological indicators for cross contamination from other • Barraquer needle holder have been met. Any failures in these services, such as orthopedic and general • Castroviejo needle holder, curved areas should be investigated before instrumentation. The following steps can (with/without lock) instrumentation is released for use. be helpful in reducing the risk of TASS: • Lancaster eye speculum Improperly-sterilized instrumentation • Barraquer eye speculum (See Figure 4) can potentially transfer harmful • Carefully following the instrument • Jeweler bipolar forceps forceps (See microorganisms to patients, resulting in manufacturer’s IFU for cleaning; Figure 5) an infection. Enzymatic solutions and • Using only enzymes and detergents detergents should be compatible with recommended by the manufacturer; Objective 2: Review toxic anterior the instrumentation and diluted and • Having a designated cleaning area for segment syndrome and ways to avoid a rinsed according to the manufacturer’s intraocular instrumentation; postoperative inflammatory reaction instructions for use (IFU). Failure to • Keeping cleaning tools separated from TASS is an acute postoperative follow the IFU and adequately rinse tools used with other services; inflammatory reaction in which a residual enzymes and detergents from • Cleaning and disinfecting cleaning noninfectious substance enters the instrumentation can cause TASS. tools regularly; anterior segment of the eye and Viscoelastic material is a solution • Flushing lumens completely in introduces toxic damage to the used in cataract surgery to create and accordance with the IFU; intraocular tissues. The inflammatory maintain space in the anterior chamber • Rinsing with the recommended critical process of TASS generally begins 24 of the eye during the phacoemulsification water for the amount and time stated hours after eye surgery; when it occurs, and implantation of an intraocular lens in the IFU; patients may experience blurred vision, (IOL), as well as protect the corneal • Allowing adequate time for ocular pain, redness and corneal endothelium. When viscoelastic reprocessing between patients; and edema. In severe cases, TASS can cause material is allowed to dry and harden on • Inspecting instrumentation under permanent damage to the iris and instrumentation, it can be difficult to see lighted magnification. impairment of the pupil and require and remove. Viscoelastic material that additional surgery to restore vision. is not removed creates an ideal place for Several factors can contribute to TASS, bacteria to grow and biofilm to form. If including sterilization process failures, not removed, microorganisms can be CIS SELF-STUDY LESSON PLAN

the lid speculum to expose the eye. or have imperfections in the blades can There are two types of lid speculums. rip and tear tissue. The tissue layers Check for debris. Electrode The first type uses a thumb screw to of the eye can be as thin as the skin tips should be intact expand the blades and retract the eye on a grape, so sharp scissors in good lids. It is important to inspect the blades working order are important. Once the to ensure they are free of nicks or burrs, incision is made, the scissors are used which could damage the eye lids during to dissect tendons and episcleral tissue Check for cracking the procedure. The thumb screw should until the sclera is reached. Bleeding or other damage move freely without having to place can occur when making the incision significant tension on it; if the thumb or during the dissection phase. The Figure 5: Jeweler Bipolar forceps screw does not move easily, refer to the Jeweler-type bipolar forceps are used manufacturer’s IFU. It is essential to only to cauterize blood vessels and control use lubricant that is approved by the bleeding. Inspection of the bipolar tips Objective 3: Discuss the function of eye manufacturer as unapproved lubricants is important because the tips of the instrumentation during an eye muscle could result in unintended inflammation, forceps act like electrodes. An electrical procedure or TASS. The second type of lid speculum current is used to cauterize as it passes The eye muscle procedure is indicated is a wire speculum, without a screw, through one side of the forceps electrode when there is a misalignment of the which provides tension on the eye lids. It and returns through the other side eyes and one or both eyes do not look is important to ensure the speculum can of the forceps electrode, restricting at the same place at the same time. provide tension; this is done by pressing the electrical current so it only passes This misalignment is called strabismus together the ends with the thumb and through the tissue between the tips or and the condition occurs as a result of index finger. The speculum should be electrodes. If the forceps tips do not poor neuromuscular eye control. Eye replaced if it does not spring back against approximate as intended, the patient alignment is important for good depth the thumb and index finger during the may be burned or harmed by cauterizing perception and for avoiding “seeing test. unintended structures. double.” When eyes are misaligned, the Once the lid speculum is in place, Once the sclera is exposed, the brain receives two separate images, which forceps are used to hold the conjunctiva Jameson and Stevens muscle hooks can create confusion and double vision. tissue, which is the clear thin membrane are used to isolate the targeted muscle. Over time, the brain will compensate and that covers the anterior part of the sclera. Muscle hooks come in different sizes and eventually ignore one of the images, Small forceps are used in eye muscle shapes. In this procedure, the Stevens which can then affect the vision of the surgery because of the thin delicate tissue hook (the smaller of the two hooks) is other eye. Without treatment, strabismus that comprise the eye. Forceps like the used to locate the muscle. When the will worsen. Bishop-Harmon and Castroviejo with muscle is found, the hook is replaced The type of strabismus is classified teeth are used to grasp the delicate tissues with the larger Jameson hook to expose by the direction in which the eye turns. in the eye. As with other forceps, it is the entire muscle. The two hooks have There are four types of strabismus: essential to check the distal tips to ensure specific functions, so it is important they approximate and the fine teeth do when assembling the tray that the correct • Esotropia – Inward turning of one or not overlap. hook be placed in the set. If a hook is both eyes; After the conjunctiva tissue is secured missing, it should not be replaced with • Exotropia – Outward turning of one or by the forceps, a Westcott tenotomy an alternative unless approved by the both eyes; scissor is then used to make the incision surgeon or Operating Room (OR) team. • Hypertropia – One eye is higher than in the conjunctiva. The scissors must be A double-ended suture is passed through the other or upward turning; and carefully inspected before sterilization. the muscle at the insertion point. • Hypotropia – One eye is lower than The Westcott scissor uses a spring action Again, since eye procedures involve the other or downward turning. to engage the blades and must be tested delicate tissue, a small suture size is before use. The blades of ophthalmology used. In this procedure, the suture used The eye muscle procedure for scissors must be sharp and free of nicks is 6-0 to 7-0 in size. The suture size correcting strabismus begins by placing and burrs. Scissors that are not sharp determines the size of the needle and CIS SELF-STUDY LESSON PLAN

needle holder to be used. The larger the visualization. It is important to check tissue is closed with suture. number in the suture size means that the locking mechanism of the Moody During an eye procedure, most the needle will be smaller in size and clamp in the assembly area before each surgeons will use a microscope or a smaller, more delicate needle holder use to ensure there is enough tension loupes to magnify the operative site. must be used. Conversely, a smaller to keep the clamp locked during use. A Loupes are glasses that are equipped number in the suture size means that malfunctioning clamp can frustrate the with built in telescopes that enhance the needle will be larger and a heavy or surgeon and delay the procedure. the field of vision. If the surgeon larger needle holder must be used. For Once the Moody clamps are in needs magnification to perform the example, during an abdominal case, one place and the eye is moved to expose procedure, this is an indication that could expect to find 0, 1-0 or 2-0 suture, the operative site, a double hook or lighted magnification should also be which would require a heavy needle Desmarres lid retractor is used to retract used in the assembly area to inspect eye holder like the Mayo-Hegar needle the conjunctiva tissue and expose the instrumentation. Note: There are several holder. To suture skin from a small new location where the muscle will variations of the eye muscle procedure. laceration on the forearm, one could be reattached. A Castroviejo caliper Objective 3 covers some but not all expect to use a 4-0 or 5-0 suture with a is then used to mark the location. If surgeon specific instrument preferences or Webster or Halsey needle holder. For the performing a lateral rectus resection, procedure styles. eye muscle procedure, a small delicate the muscle would be placed posterior Castroviejo needle driver is needed to to the insertion point. The calipers play Conclusion accommodate the small 6-0 and 7-0 a crucial role in the procedure and are The eye muscle procedure to correct suture. When inspecting the Castroviejo used for precise measurement of the strabismus could not be successful needle driver, it is important to check the structures of the eye. The calipers in this without the knowledge of the CS/SP spring and locking function to ensure the procedure will mark the new attachment instrument technician. CS/SP technicians instrument can hold the suture needle in point for the muscle, which is essential who understand the importance of place. Often, a needle holder can become in correcting the strabismus. The caliper instrument inspection and testing and magnetized. A magnetized instrument resembles a V-shape, with very fine distal are familiar with how instrumentation can be difficult to use during surgery, tips and a horizontal measuring bar at is used during a procedure are better especially when working in small spaces the proximal end. The box lock area has equipped to prevent adverse patient with small needles. When inspecting a large holding screw. It is important outcomes. the needle driver, check the instrument to ensure the screw is intact, clean and for magnification and take steps to functioning properly. The proximal Resources demagnetize, if necessary. end has a screw-type device to hold the International Association of Healthcare Central After the muscle is sutured, two distal tips open or closed, depending Service Materiel Management. Central Service Moody locking clamps are placed at upon the desired measurements. During Technical Manual. Chapter 8, Cleaning and each end of the muscle, at the original inspection, it is essential to ensure the Decontamination. P. 155. 2016. insertion point. The muscle is then distal tips are clean, intact, free from cut and separated from the sclera. The burrs, and not bent. The tips on the International Association of Healthcare Central Moody locking clamp resembles the caliper are used to measure and mark the Service Materiel Management. Instrument Castroviejo forceps in size and shape, and precise location to reattach the muscle. Resource Manual. Chapter 16, Ophthalmic (Eye) both have small teeth that approximate at When the calipers have marked the Instruments. P. 266. 2018. the distal tip to allow for grasping of fine new location for the muscle, the muscle tissue. One distinct difference between is then sutured into place using the Alexander’s. Care of the Patient in Surgery, Chapter the Castroviejo forceps and Moody Castroviejo locking needle driver. After 25, Pediatric Surgery. P. 1127. 2011. clamp is the curved shape of the Moody the muscle is secured, the placement of clamp and locking mechanism. When the muscle is rechecked with the calipers Association for Advancement of Medical the Moody clamp is used, it is clamped to ensure correct placement. To complete Instrumentation. ANSI/AAMI ST79: Comprehensive and locked to the sclera and follows the the eye muscle procedure, the double Guide to Steam Sterilization and Sterility Assurance contoured shape of the eye to allow the hook or Demarres retractor and Moody in Health Care Facilities. 2017. surgeon to manipulate the eye for better clamps are removed and the conjunctiva CIS Self-Study Lesson Plan Quiz - Ophthalmic Surgical Instruments Lesson No. CIS 272 (Instrument Continuing Education - ICE) • Lesson expires March 2022

1. Which of the following instruments would 7. Which of the following is a solution 12. Which instrument uses electrical current not be found in a basic eye muscle set? used in cataract surgery to create and to control or stop bleeding? a. Jameson muscle hook maintain space in the anterior chamber a. Barraquer lid retractor b. Hurd dissector and Pillar retractor of the eye during the phacoemulsification b. Moody locking forceps c. Castroviejo caliper and implantation of an intraocular lens? c. Jeweler bipolar forceps d. Desmarres lid retractor a. Viscoelastic material d. Castroviejo forceps b. Vancomycin 2. Which of the following instruments is not c. Saline solution 13. Which size suture and needle holder the name of a hook? d. None of the above combination would be appropriate for a. Jameson suturing the muscle to the sclera during b. Graefe the eye muscle procedure? c. Stevens tenotomy 8. The eye muscle procedure is indicated a. 1-0 suture and Mayo-Hegar needle d. Barraquer when there is a misalignment of the eye holder or eyes. This misalignment is called: b. 2-0 suture and Castroviejo needle 3. TASS stands for: a. Striations holder a. Toxic anterior segment syndrome b. Astigmatism c. 6-0 suture and Castroviejo needle b. Toxic angular segment syndrome c. Cataract holder c. Toxic anterior section syndrome d. Strabismus d. 7-0 suture and Mayo-Hegar needle d. Toxic anesthetic segment syndrome holder 9. Which of the following best describes the 4. TASS is an acute postoperative condition exotropia? 14. Magnification is not necessary inflammatory reaction in which a a. Inward turning of one or both eyes when inspecting and assembling eye noninfectious substance enters a portion b. Outward turning of one or both eyes instrumentation. of the eye and introduces toxic damage to c. One eye is higher than the other or a. True the intraocular tissues. upward turning b. False a. True d. One eye is lower than the other or b. False downward turning 15. To complete the eye muscle procedure, the double hook or Demarres retractor 5. Which of the following is not a symptom a 10. Which of the following best describes the and Moody clamps are removed and: patient may experience with TASS? condition hypotropia? a. The conjunctiva tissue is closed with a. Blurred vision a. Inward turning of one or both eyes suture b. Ocular pain b. Outward turning of one or both eyes b. The sclera tissue is closed with suture c. Color blindness c. One eye is higher than the other or c. The instruments should be discarded d. Corneal edema upward turning d. None of the above d. One eye is lower than the other or 6. Which of the following is not helpful in the downward turning reduction of TASS? a. Carefully following the instrument 11. The initial incision made during the eye manufacturer’s cleaning instructions muscle procedure is made in which layer b. Using only one enzyme or detergent of tissue? for all instruments a. Sclera c. Flushing lumens completely according b. Conjunctiva to the instructions for use c. Retina d. Allowing adequate time for d. Choroid reprocessing between patients

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