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CIS
Instrument Continuing Education (ICE)
SELF-STUDY PLANS

Instrument Continuing Education (ICE) lessons provide members with ongoing education in the complex and ever-changing area of surgical instrument 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 single lesson plan, or bundled packages are available for quantities of 6 lessons for $25 (save $5) or 12 lessons for $50 (save $10) for greater savings).

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 of the ICE Lesson Plans).

Lesson Plan CIS 206
Ophthalmology Instrumentation
[Reprinted from Communiqué: March/April 2008]

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 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.