BEST PRACTICES Attention to detail with every instrument and every patient are essential.

There's a tremendous amount of equipment in ophthalmology that you need to very carefully clean and maintain, and scrupulous attention to detail is vital. Here are 8 tips that can prolong the lives of instruments, protect patients from harm and avoid expensive repair bills.

1. Clean and flush thoroughly. Ophthalmic surgeons nationwide got a big wakeup call a few years ago, when numerous cases of toxic anterior segment syndrome (TASS) suddenly began cropping up in patients who'd had cataract surgery. Almost unheard of before 2000, the condition became a needle in a haystack as experts tried to figure out what was causing it.

The search for the cause of TASS eventually put inadequate cleaning practices under the microscope. Instruments might have looked to the naked eye as if they were being adequately cleaned before being autoclaved, but minute remnants were sometimes left behind, particularly in cannulated instruments. And when endotoxins were introduced into the next patient's eye, they were released, causing the dangerous inflammatory reaction.

Further complicating the issue was that sometimes the solution was part of the problem — meaning sediment from the soap or solution used to wash instruments wasn't always being adequately rinsed. One result is that to this day there's still a divide among professionals as to whether you should clean instruments with water only, or whether it's better to use a detergent cleanser.

This much is clear: If you're using a detergent, it's absolutely essential that it's meant for ophthalmic instruments, that it has the right alkalinity, that you follow manufacturer's directions, and that you rinse it, rinse it, and rinse it again, to make sure everything is out of your cannulas. Using an automated rinse system is a good way to flush handpieces and cannulated instruments to ensure you're eliminating any debris and leftover cleaning solution.

Regardless of which camp you fall into, people seem to be getting the message. We're seeing far fewer TASS cases now. But we're still seeing a few, which suggests that some people may be taking shortcuts during instrument cleaning, or not being as meticulous as they need to be. Even when you're getting new instruments from the manufacturer, you need to make sure they're rinsed adequately before you put them into your instrument sets.

TURNOVER TIP Ensure staff know how to properly reprocess every instrument you use, including delicate blades.

2. Protect diamond blades. Diamond blades can be very cost effective, because you can use them over and over again for long periods of time, but they're also very expensive to repair. You'll likely pay between $1,000 and $1,500 every time a diamond knife needs to be sent out.

So, protect your investment. Unless the blade is actually being handed to a surgeon, the guard that covers the tip should be up, so the blade is never unnecessarily exposed. To clean diamond blades, use specially designed pads available from several manufacturers. They work by having the blade cut through 3 gel-like materials in sequence. The first contains a cleaning solution, the second and third purified water. A few passes through the pads should remove any debris before the blade is sterilized.

We use diamond blades exclusively, but the reposable gem blades several companies now offer are intriguing. That compromise between long-lasting diamond blades and single-use blades may turn out to be cost-effective, though the jury is still out. Again, proper care might make the difference: If careful maintenance can extend the life of reposable blades to 50-plus cases, that could save money.

3. Wash separately. People don't always realize that if you have some instruments that are made out of stainless steel and some that are made out of titanium, for example, you can't wash them together. Different materials require different procedures. Be sure to follow manufacturers' instructions. Instruments need to be cleaned by hand and put delicately in an ultrasound basket. You can't just toss them all together and shake them up. Also, instruments such as scissors or needle-holders should always be autoclaved in the open position to ensure they're properly sterilized.

4. Arrange with caution. When you place instruments in trays, make sure the tip covers are on them. And with very delicate instruments, be sure to use a tray that has a silicone pad on the bottom. The best pads feature finger-like holders; the instruments fit between the fingers, so the tips aren't coming into contact with each other.

5. Don't wait to wash. Flush cannulated instruments as soon as they're done being used on the sterile field. Also, keep all instruments moist on the sterile field, so the viscoelastics don't accumulate in the cannulas, and debris doesn't accumulate on the blades of your scissors or on the tips of your forceps. Once you're not using an instrument, put it in sterile water on your back table, so its surface remains moist.

6. Limit immediate-use sterilization. Some immediate-use sterilization (flashing) will always be necessary. If you drop an instrument and it's a one-only — or maybe you have 2, but you have doctors working in 2 rooms — you have to do what you have to do. But if you're wrapping and sterilizing your sets at the end of the day, and using those instruments the next morning, you should be doing the same for every one of your patients throughout the day. Every patient deserves the same standard of care. If you're flashing under any other scenario than the one described above, it probably means you don't have an adequate number of instrument trays to meet surgeon needs without cutting corners.

NO TOUCHING Arrange instruments for reprocessing so tips never come into contact with each other.

7. Consider service contracts. We have our big-ticket items, such as phacoemulsification handpieces, under service contracts. If we have a problem with anything, the handpiece can be changed out and we can usually get a replacement within a day or two. It's comforting, because we have a lot of handpieces to take care of, and we know if one goes down, we can not only get it replaced very quickly, but also at reasonable cost.

8. Keep references handy. Be sure to have manufacturers' handbooks that accompany all instrumentation and have directions for use and cleaning near the reprocessing area. I also recommend that you have on hand the guidebook Care and Handling of Ophthalmic Microsurgical Instruments (tinyurl.com/lmvczo2). When there's staff turnover, new people have to understand why they're reprocessing instruments certain ways and what can happen if they do things improperly or cut corners. They need to understand why it's important to repetitively do the same things on every single case and on all of the instruments that they take care of.