CARE AND HANDLING Protective guards and sterilization trays aren't always included with your instrument purchases.

When it comes to buying ophthalmic instruments, the devil is in the details. Some instruments, for example, have special injectors that you have to purchase separately. Do the delicate tips gap or rust? Do you need a special processing tray to accommodate instruments that must sit with their prongs up or to the side when you sterilize them? We asked a panel of 23 ophthalmic administrators several questions related to their ophthalmic instrument purchasing habits. Here's a recap.

1 Can you trial ophthalmic instruments before purchasing?
Eighteen of our 23 respondents say yes, they can trial instruments. Another 4 can do so only if the rep is present. "Unless your center has money it can afford to give away, you should be allowed to trial any instrument prior to purchasing," says Lisa Waters, RN, chief operating officer at the Columbia (S.C.) Eye Surgery Center. "A representative from the company should be present to answer any questions and to give instruction to the physician or operating personnel during a case." A good idea: Schedule the trial when the physician is working and will need the instrumentation that you're considering. "This is good practice," says Ms. Waters. "It's like test driving a car before you say 'yes.' If the rep is focused on customer service instead of just turning a profit, he'll let the center trial the instruments for at least 1 to 2 weeks."

2 Are protective guards and sterilization trays typically included with your instrument purchases?
More than one-fourth (28.6%) of our panel replied no, 14.3% said yes and 57.1% said sometimes. "Usually protective guards and occasionally a sterilization tray," says Janet Johnson, RN, clinical director of the Eye Surgery Center of Hinsdale (Ill.). You don't want to find out after the fact that you also have to order a sterilization tray in addition to having to pay for the instruments. "Don't be afraid to ask for protective casing, guards or even trays that you can use for sterilization," says Ms. Waters. Some instruments might come in foam packing in a labeled box. "In this case, be sure to ask if a sterilization case or tray is available," she says.

3 Do you research whether ophthalmic instruments you're considering will be compatible with your sterilization system?
Only 2 of our panelists don't take this extra step. "Most ophthalmic instruments are stainless steel or titanium, which are both steam-sterilizable," notes Jackie Dayton, RN, nursing supervisor of the Surgery Center of Ophthalmology Consult-ants in Fort Wayne, Ind. A clinical director at a Pennsylvania eye ASC suggests that you research the type of cycle and length of time needed for sterilization. "Nothing's worse than purchasing an instrument and it not fitting into your current sterilization system," says Ms. Waters. Research whether the instrument will fit into your sterilization system, be it gas, steam or ultrasonic cleanser, she says.

4 Do you prepare sub-specialty trays for some of your eye surgeons?
Sentiment here was split. Some facility managers say they're a great help for turnover time as well as for pulling cases, while others believe it's more economical and efficient to standardize your eye instrument trays.

"Specialty trays are a huge help," says Charlotte Alford, RN, manager of the Eye Surgery Center in Shreveport, La. "They provide faster turnovers, convenience with all items in 1 set, less time opening instruments. Plus, they minimize cost — fewer sterilization supplies needed — and minimize staffing requirements. You may spend more money upfront, but the dividends pay off in the end."

At the Eye Surgery Center of Hinsdale, standardized cataract trays also include 3 different choices for each doctor's "second" instrument for use during phacoemulsification, a Thornton Ring that just 1 surgeon uses, and instruments in case a surgeon has to convert the case to extracapsular cataract extraction or has to place a suture, says Ms. Johnson. "This reduces the need to open separate instruments for each surgeon, and we don't have a tremendous amount of differences in our surgeons' instruments to make trays overburdened and confusing," she says.

One respondent separates her sets by service: cataracts, glaucoma, retina and plastics. "Some doctors have a set or 3 extra instruments that they use every case that we peel-pouch for them," she says. "It makes for happier doctors and easier turnovers for our central processing department."

5 How have you overcome the major challenge in the care and handling of your ophthalmic instruments?
Ophthalmic instruments are very delicate and expensive to replace. At the Eye Surgery Center of Hinsdale, Ms. Johnson says she educates all staff on the ASCRS-recommended methods of instrument decontamination and sterilization as well as the manufacturer's directions for use for each item. Ms. Johnson shares what else her facility does to care for its instruments:

• Wipe all instruments with an instrument wipe and soak them in a basin of sterile water on the field to prevent viscoelastic from drying and sticking on instruments or in lumens.

• Submerge the entire cataract tray — except for handpieces and diamond knives — in a large ultrasonic bath of water and non-enzymatic cleaning solution for 3 minutes.

• Immediately following instruments' use in surgery, use an automated instrument rinse system to flush 120ml of sterile distilled water and 60ml of air through each lumen of the I/A handpieces and tips, and through the phaco handpieces' lumens. "We've also done this with 60ml syringes, but it's very labor-intensive and I find staff is tempted to cut corners on the amounts of water," says Ms. Johnson.

• Submerge the tips of diamond knives into the ultrasonic bath for 1 minute, and then rinse them thoroughly, including using a syringe to squirt sterile distilled water cautiously into the lumen and then flushing with a syringe full of air.

• Rinse trays and instruments thoroughly, and dry the trays before wrapping and sterilizing them according to manufacturer's sterilization recommendations.

• Change the water in the ultrasonic unit daily. Also clean and thoroughly dry the ultrasonic according to the manufacturer's directions.

"We don't have a tremendous amount of differences in our surgeon instruments to make trays overburdened and confusing."

— Janet Johnson, RN, clinical director of the Eye Surgery Center of Hinsdale (Ill.)

6 How many different types of ophthalmic knives do you regularly stock for cataract surgery?
The trend among our respondents is to standardize ophthalmic knives: 41% of our panel says all surgeons use the same type of knife. "We do try to standardize supplies, but [physicians] stick to their preferences, mostly for knives," says Ellen Beltramba, RN, COT, CRNO, of the Eye Surgery and Laser Center in Winter Haven, Fla.

Most respondents (68.2%) stock diamond knives, while 59.1% use steel. "We have 1 type of 2.2mm diamond keratome and 1 1.0mm sideport diamond or trial sapphire knife," says Ms. Johnson. "My surgeons find sapphire blades dull for keratome use, but will use them for sideports." Diamond blades can be tricky to clean and keep sharp. They can get micro divots which require rehoning, says Lauren Belleza, ATA, administrator of the Physicians Eye Surgery Center in Everett, Wash.

Nearly one-third (31.8) of respondents dispose of a knife after a single use and about one-fourth (27.3%) reuse their knives. Most respondents (40.9%) stock both disposable and reusable knives.