Why Enzymatic Pretreatment Products Are Not Appropriate for Ophthalmic Instruments

Developing Your Skills Do You Know Why? The Stitch

By: Sarah Hernandez, BSN, RN, Erica Groning Gomes, BSN, RN, and Nancy Do, BSN, RN

Published: 8/14/2025

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Pretreating used surgical instruments with an enzymatic agent after a surgical case is recommended.¹ These agents help keep instruments wet and begin breaking down bioburden prior to arrival of instruments in the decontamination area of the sterile processing department. If this pretreatment process is not performed, soils, including bioburden, may dry on the instruments and make it more difficult to clean the instruments.² National ophthalmic organizations, however, recommend avoiding routinely using enzymatic products on instruments that are used in the eye,³ and many nurses often wonder why these instruments are an exception.

Enzymatic Products and the Eye

The human eye is one of the most delicate areas to operate on, and eye procedures require special precautions when reprocessing the surgical instruments used. Enzymatic products are not appropriate for ophthalmic surgical instruments because of the potential for improper removal of the product after application. Not only do the small lumens of the instruments make complete removal of the enzymatic products nearly impossible,⁴ available literature suggests that enzymatic detergents can contain α-amylase and the exotoxin subtilisin, neither of which are denatured by routine steam sterilization.⁵ Corneal endothelial toxicity from enzymatic detergents also has been documented in both animal and human studies.⁵ Although not a detergent, when an enzymatic product is used for pretreatment, there is potential for residue after cleaning, decontamination, and sterilization. Moreover, the use of enzymatic products on ophthalmic surgical instruments may place the patient at increased risk for complications, such as toxic anterior segment syndrome (TASS).⁴

Best Practice

Nurses should be cognizant of evidence-based practice recommendations to help ensure optimal patient outcomes. Ophthalmic instruments have been found to have little bioburden during surgery and rinsing and presoaking with sterile water is sufficient to remove bioburden.¹ Therefore, it is best practice to rinse these instruments with sterile distilled or sterile deionized water during the procedure.

References:

  1. Guideline for instrument cleaning. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2025.
  2. Daigle P. Your guide to enzymatic cleaners. Outpatient Surgery. November 1, 2016. Accessed June 25, 2025.
  3. Guidelines for the cleaning and sterilization of intraocular surgical instruments. American Academy of Ophthalmology. Accessed June 25, 2025.
  4. Academy of Ophthalmology. Guidelines for the cleaning and sterilization of intraocular surgical instruments – 2018. April 2018. Accessed June 25, 2025.
  5. Parikh C, Sippy BD, Martin DF, Edelhauser HF. 2002. Effects of enzymatic sterilization detergents on the corneal endothelium. Arch Ophthalmol. 2002;120(2):165-172.

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