Surgical Instruments Brothers Jaypeepostgraduatebooks.jaypeeapps.com/pdf/Opthalmology/...in various textbooks and two textbooks and 4 educational books and manuals. He has received

Ophthalmic Surgical Instruments

Rajesh Sinha MD DNB FIACLE FRCS Professor

Cornea, Lens and Refractive Surgery ServicesDr Rajendra Prasad Centre for Ophthalmic Sciences

All India Institute of Medial SciencesNew Delhi, India

Jeewan S Titiyal MDPadma Shri AwardeeProfessor and Head

Cornea, Cataract and Refractive Surgery ServicesDr Rajendra Prasad Centre for Ophthalmic Sciences

All India Institute of Medical SciencesNew Delhi, India

Vijay Kumar Sharma MSConsultant

Advanced Centre for Ophthalmic and Visual SciencesArmy Hospital Research and Referral

New Delhi, India

ForewordAmar Agarwal

New Delhi | London | PanamaThe Health Sciences Publisher

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Website: www.jaypeebrothers.comWebsite: www.jaypeedigital.com

© 2017, Jaypee Brothers Medical Publishers

The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book.

All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers.All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity.

Inquiries for bulk sales may be solicited at: [email protected]

Ophthalmic Surgical Instruments

First Edition: 2017

ISBN 978-93-86322-97-5

Printed at

HeadquartersJaypee Brothers Medical Publishers (P) Ltd4838/24, Ansari Road, DaryaganjNew Delhi 110 002, IndiaPhone: +91-11-43574357Fax: +91-11-43574314Email: [email protected]

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Jaypee Brothers Medical Publishers (P) Ltd


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Dedicated toThe three special women in my life,

My mother, Malti, for her care and blessings,My wife, Renu, for her support and

My daughter, Suhani, for her loving smile— Rajesh Sinha

My wife, Mrs Basanti Titiyal,My children, Dr Hemant Titiyal and Dr Renuka Titiyal

— Jeewan S Titiyal

My wife, Dr Manisha My daughter, Naisha

—Vijay Kumar Sharma


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Chintan J DedhiaFellowVitreoretinal ServicesLV Prasad Eye InstituteHyderabad, Telangana, India

Dewang AngmoAssistant ProfessorDr Rajendra Prasad Centre for Ophthalmic SciencesAll India Institute of Medical SciencesNew Delhi, India

Digvijay SinghConsultantMedanta – The MedicityGurugram, Haryana, India

Jeewan S TitiyalPadma Shri AwardeeProfessor and HeadCornea, Cataract and Refractive Surgery ServicesDr Rajendra Prasad Centre for Ophthalmic SciencesAll India Institute of Medical SciencesNew Delhi, India

Manpreet KaurSenior ResidentDr Rajendra Prasad Centre for Ophthalmic SciencesAll India Institute of Medical SciencesNew Delhi, India

Neha KambleSenior ResidentDr Rajendra Prasad Centre for Ophthalmic SciencesAll India Institute of Medial SciencesNew Delhi, India

Nitin VichareClassified SpecialistCommand Hospital (Central Command)Lucknow, Uttar Pradesh, India

Rajesh SinhaProfessorCornea, Lens and Refractive Surgery ServicesDr Rajendra Prasad Centre for Ophthalmic SciencesAll India Institute of Medial SciencesNew Delhi, India

Ravi BypareddyAssistant ProfessorMinto Ophthalmic HospitalBangalore Medical College and Research InstituteBengaluru, Karnataka, India

Reena K SinghSenior ResidentDr Rajendra Prasad Centre for Ophthalmic SciencesAll India Institute of Medial SciencesNew Delhi, India

Contributors


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Rohan ChawlaAssistant ProfessorVitreoretinal ServicesDr Rajendra Prasad Centre for Ophthalmic SciencesAll India Institute of Medial SciencesNew Delhi, India

Rohit SaxenaProfessorDr Rajendra Prasad Centre for Ophthalmic SciencesAll India Institute of Medial SciencesNew Delhi, India

Roshan TFellowNarayana NethralayaBengaluru, Karnataka, India

Sandeep GuptaReaderArmed Forces Medical CollegePune, Maharashtra, India

Supriya AroraConsultant Eye Care CentrePrincess Margaret HospitalNassau, New Providence, Bahamas

Tarun AroraConsultant Eye Care CentrePrincess Margaret HospitalNassau, New Providence, Bahamas

Vijay Kumar SharmaConsultantAdvanced Centre for Ophthalmic and Visual SciencesArmy Hospital Research and ReferralNew Delhi, India

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Dr Rajesh Sinha, Professor of Ophthalmology in Cornea, Lens and Refractive Surgery Services at Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India; Dr Jeewan S Titiyal, Professor and Head of the Cornea, Cataract and Refractive Surgery Services at Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, and Dr (Lt Col) Vijay Kumar Sharma, an alumnus of the prestigious Armed Forces Medical College (AFMC), Pune, Maharashtra, India are to be congratulated for attempting and accomplishing the almost impossible task of assembling in one place the various surgical instruments used in modern ophthalmic surgery with the help of systematically arranged photographs. Making the information correct and complete is winning only half the battle; the other half is using a format that helps students assimilate and apply it. The book with the help of a broad range of photographs laid out in a rational and effective fashion, resulting in a creative and unique atlas, is suitable for all levels of eye-care professionals, students in training, residents in ophthalmology as well as budding practitioners. It is an honor for me to be invited to write the foreword for this book, which was compiled by my esteemed colleague, Dr Rajesh Sinha, has 324 publications to his name; 127 are in indexed journals; 77 chapters in various textbooks and two textbooks and 4 educational books and manuals. He has received various awards and orations and when I saw him doing live surgery once I was just gasping at his surgical skill. Dr Jeewan S Titiyal is the first Indian to perform live surgery demonstration in ASCRS, USA. Dr (Lt Col) Vijay Kumar Sharma is Consultant at Army Hospital Research and Referral, New Delhi and is involved in teaching postgraduate and undergraduate students. They have my congratulations and admiration for a thoughtful and handsome job well done.

Amar Agarwal MS FRCS FRCOphthalChairman

Dr Agarwal’s Group of Eye HospitalsDr Agarwal’s Eye Hospital and Eye Research Centre

Chennai, Tamil Nadu, IndiaEmail: [email protected]

Foreword


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Ophthalmic surgery is evolving at a rapid pace with the introduction of newer techniques and technology. Various newer surgical instruments are being added to the ever-expanding kit of the ophthalmologists. Most of the postgraduate and undergraduate students do not have access to the newer surgical instruments and find it difficult to answer the questions related to these newer instruments in the examinations. There is no dedicated book on the surgical instruments at present, and this topic is simply discussed in the last few pages of some of the ophthalmology textbooks with inadequate photographs and description about the instruments. We felt that there is need of a book which exclusively deals with the instruments used in ophthalmic surgery with description about their specifications and uses so that postgraduates, fellows and general ophthalmologists can learn about the finer aspects and uses of these instruments. This book provides comprehensive description and colored photographs about the instruments used in various ophthalmic surgeries, including those being used in cornea and refractive surgery, retinal surgeries, squint and oculoplastic surgeries, glaucoma surgery, cataract and femtocataract surgery as well as sterilization techniques of these instruments. Each chapter is devoted to surgical instruments used in a particular subspecialty of ophthalmology. Original photographs of good quality with a similar background in majority of the chapters have been used not only to maintain a uniformity but also to provide crisp visuals of each instrument. This book will not only help the undergraduate and postgraduate students but also the young practitioners who are planning to establish their own set-up, as they get a sort of checklist for the instruments that they have to purchase as well as an accurate information about their exact uses. Despite our best efforts, the book may have some inaccuracies. Feedback from teachers and students are most welcomed and will help in the improvement of the book in the future. We sincerely hope that this book will be of immense help and useful guide for the residents, fellows and general ophthalmologists alike.

Rajesh Sinha Jeewan S Titiyal

Vijay Kumar Sharma

Preface


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1. Basic Instruments in Ophthalmic Surgery 1 Sandeep Gupta, Vijay K Sharma • Lid Speculums 1 • Forceps 2 • Eye Scissors 5 • Needle Holder 7 • Callipers 8 • Instrument Box 9

2. Instruments for Cataract Surgery 10 Manpreet Kaur, Roshan T, Jeewan S Titiyal • Thermal Ball Point Cautery 10 • Electrocautery 10 • Bard Parker Knife Handle with Blade 11 • Microvitreoretinal Blade 12 • Side Port/Stab Knives 13 • Crescent Knife 13 • Keratome 14 • Cystotome 14 • Microcapsulorhexis Forceps 15 • Smith Lens Expressor (Lens Hook) 15 • Wire Vectis 16 • McIntyre Irrigating Wire Vectis 16 • Simcoe Irrigation–Aspiration Cannula 17 • J-shaped Double Irrigation–Aspiration Cannula 18 • Sinskey Hook 18 • Chopper 19 • Phacoemulsification Probe and Tips 20 • Infusion Sleeves 21 • Iris Repositor 22 • Coaxial Irrigation–Aspiration Handpiece 22 • Bimanual Irrigation–Aspiration Handpiece 23 • Cannula 23 • Anterior Chamber Maintainer 24 • Von Graefe Knife 24 • Arruga Capsule Forceps 25 • Kirby Lens Expressor and Repository 25 • Kirby Lens Expressor and Vectis 26

Contents


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• Lens Holding Forceps 26 • Lens Folding Forceps 26 • IOL Injector 26 • Autosert 27 • Stevens Femtosecond Flap Lifter 28 • Krokchings Femto Incision Opening Spatula 28 • Cionni Femto Spatula and Nucleus Divider 28 • Dr Rana’s Double Tooth Phaco Chopper 29

3. Instruments Used in Refractive Surgery 31 Tarun Arora, Rajesh Sinha, Jeewan S Titiyal • Various Instruments Used in Cornea-based

Refractive Surgery 31 • Instruments Used for Implantable Collamer Lens

Based Surgery 35 • Instruments for Femtosecond Assisted Intacs 36

4. Instruments for Corneal Surgeries and Eye Banking 38 Reena K Singh, Rajesh Sinha, Jeewan S Titiyal • Instruments Used for Eye/Corneoscleral Button Retrieval 39 • Specular Microscopy in Eye Bank 43 Corneal Surgery Instruments 44 • Different Types of Speculum 44 • Superior Rrectus Fixation Forceps 45 • Flieringa Scleral Fixation Rings 45 • Scale 46 • Castroviejo Calliper 46 • Radial Keratotomy Marker 47 • Teflon Corneal Blocks 47 • King’s Clamp 48 • Razor Blade Breaker and Holder 48 • Diamond Knife 49 • Hand-held Corneal Trephines 49 Microlamellar Dissectors 50 • Devers-Terry Straight and Curved Lamellar Dissectors 50 • Gill’s Lamellar Dissector 50 • Tooke’s Knife 51 • Cyclodialysis Spatula 51 • Flap Lifter double-ended 51 • DSAEK Spatula 52 • Reverse Sinskey Hook 52 • Miniperforated Spoon/Graft Shifter 52 • Ogawa DSAEK Graft Holding Forceps 53 • Busin Glide 53

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• DSAEK Busin Forceps 54 • Small Incision Manipulating Forceps 54 • Moria Lamellar System for Keratoplasty 54

5. Instruments for Strabismus Surgery 57 Rohit Saxena, Digvijay Singh • Speculum 57 • Scissors 59 • Needle Holder 61 • Caliper 62 • Blade Holders 63 • Forceps 63 • Muscle Hooks 65 • Muscle Clamps 69 • Retractors 70 • Miscellaneous Instruments 71

6. Instruments Used in Oculoplasty Surgeries 73 Nitin Vichare • Forceps 73 • Scissors 75 • Retractors 77 • Needle Holders 80 • Lid Spatula (Eye Guard) 81 • Nettleship’s Punctal Dilator 82 • Bowman Probes 82 • Caliper 83 • Kerrison Rongeurs (Bone Punch) 84 • Lacrimal Sac Dissector and Curette 85 • Freer Periosteal Elevator 85 • Chisel and Hammer 86 • Ptosis Muscle Clamp 86 • Entropin Clamp 87 • Wright Facia Needle 87 • Enucleation Spoon 88 • Evisceration Scoop 88

7. Instruments for Glaucoma Surgeries 89 Dewang Angmo, Neha Kamble • Crescent Blade (Sclerocorneal Splitter) 89 • Razor Blade Fragment with Blade Holder 89 • Westcott’s Spring Scissors 90 • Vannas Scissors 91 • DeWecker Iris Scissors 91 • Kelly Descemet’s Membrane Punch 92

Contents xv


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• Harms Trabeculotomy Probe 93 • Glaucolight-illuminated Fiberoptic Microcatheter 93 • Cyclodialysis Spatula 94 • Surgical Super Absorbent Spears/Sponges 95 • Biodegradable Collagen Matrix 95 • Ahmed Glaucoma Valve Tube Insertion Forceps 97 • Surgical Goniolenses 97 • Glaucoma Drainage Devices 99

8. Instruments Used in Vitreoretinal Surgeries 101 Ravi Bypareddy, Chintan J Dedhia, Rohan Chawla • Instruments Used in Scleral Buckling Surgery 101 • Instruments Used in Vitreoretinal Surgery 104

9. Needles and Sutures in Ophthalmology 121 Tarun Arora, Supriya Arora, Rajesh Sinha, Jeewan S Titiyal • Needles 121 • Sutures 125

10. Sterilization of Surgical Instruments 132 Manpreet Kaur, Roshan T, Rajesh Sinha, Jeewan S Titiyal • Cleaning of Instruments and Equipment 133 • Inspection 135 • Packaging 135 • Sterilization 136 • Sterile Storage 143 • Quality Assurance 143

Index 147

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Instruments Used in Refractive Surgery

INTRODUCTIONRefractive eye surgery is any eye surgery used to improve the refractive state of the eye and decrease or eliminate dependency on glasses or contact lenses. This can include various methods of surgical remodeling of the cornea or implanting intraocular lenses with or without cataract surgery.

VARIOUS INSTRUMENTS USED IN CORNEA-BASED REFRACTIVE SURGERY

Lieberman Temporal SpeculumAn appropriate speculum must be selected to provide adequate exposure of the globe for placement of the microkeratome vacuum ring. Most surgeons prefer the adjustable Lieberman speculum that retracts the lids sufficiently to provide unobstructed access for the microkeratome. Several models are available with and without aspiration. It is a temporal speculum with Kratz-style open wire blades along with adjustable mechanism resting on nasal bridge (Figure 1).

Tarun Arora, Rajesh Sinha, Jeewan S Titiyal

3Chapte r

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Ophthalmic Surgical Instruments32

Figure 1: Lieberman self-retaining speculum

SoftFitTM Patient InterfaceIt is a one-piece design of the LenSx® Laser’s SoftFitTM Patient Interface and connects to the counter-balanced, floating laser objective head (Figure 2).

Figure 2: Patient interface

The interface produces a 66% reduction in laser energy, along with an IOP rise of only 16 mm Hg above baseline. Additionally, the exclusive hydrogel lens technology of the patient interface is designed to:

• Minimize corneal distortion compared to solid interfaces • Reduce intraocular pressure to the cornea compared with solid

interfaces• Fixate the eye, enhancing control of movement compared to

liquid interfaces.

LASIK Flap MarkerCorneal markers are designed to place identifying patterns on the cornea. A single round marker is commonly used to facilitate the centration of the microkeratome vacuum ring. Various markers with asymmetrical rings are available to provide landmarks for realignment of the flap and for identifying the epithelial side of a loose flap (Figure 3).

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Instruments Used in Refractive Surgery 33

Figure 3: LASIK flap marker

FemtoLASIK Flap Spatula Double EndedSpecific instruments have been designed for handling the flap. This can be done with a spatula or a forcep. Spatulas typically have a beveled front edge, to easily enter the flap interface, and smoothly rounded surface to elevate and reposit the flap. They are double-ended instrument to unstick and lift the corneal flap in LASIK procedures. The delicate hook works at the flap edges inside the groove. The ”C” shaped tapered loop, once positioned below the flap, and lifts it with a gentle push on the horizontal plane; from the hinge to the exit point (Figure 4).

Figure 4: FemtoLASIK flap spatula double ended

Flap ProtectorsThese shield the corneal flap during excimer laser ablation. They have a dull finish to minimize reflections. Various models are available to protect either nasally or superiorly hinged flap (Figure 5).

Figure 5: LASIK flap protecor

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LASIK Irrigation CannulaCannulas are used for irrigating the eye before and after reposition of flap. They are designed to enter the interface with ease and are available in various models with single or multiple ports. It has a fluted-front opening, slightly curved, port that is 26 gauge and is 12 mm in length from angle to tip (Figure 6).

Figure 6: LASIK irrigation cannula

Hockey Epithelium Removal KnifeHockey knife can be used to remove epithelium during PRK procedures and during LASIK retreatment. It has a round handle with approximately 130 mm of length (Figure 7).

Figure 7: Hockey epithelium removal knife

Camellin-style LASEK Trephine 8.0 mm and 9.0 mmIt is a double-ended trephine with 8.0 mm and 9.0 mm diameter trephines on either side of a flat handle (Figure 8).

Figure 8: Camellin-style LASEK trephine

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INSTRUMENTS USED FOR IMPLANTABLE COLLAMER LENS (ICLTM) BASED SURGERY (FIGURE 9)

Figure 9: Instruments for ICLTM surgery

Coaxial Forceps for ICL™ Lens Loading, Angled TipsThis forcep is designed to assist in the correct positioning of the ICL near the injector tip before insertion. It is a 20-gauge retinal-style instrument that features special jaws with a series of convex and concave surfaces for grasping the lens without damaging the optics (Figure 10).

Figure 10: Coaxial forceps for ICLTM lens loading, angled tips

Spatula for ICLTM

This spatula is designed to aid in the proper placement of an ICL. After the lens has been inserted, the finely textured, micro-ring tips are used to position the haptic into the sulcus (Figure 11).

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Figure 11: ICL spatula

INSTRUMENTS FOR FEMTOSECOND ASSISTED INTACS

Intacs Pocketing HookMade up of titanium, pocketing hook initiates the delamination at the base of the incision by applying a slight amount of tension to the corneal tissue (Figure 12).

Figure 12: Intacs pocketing hook

Intacs Glide Blade Handle with Symmetric GlideStainless steel handle that has been specifically designed so as to be used with the detachable symmetric glide (Figure 13). The bifurcated glide instrument is also made up of stainless steel, and is inserted into entry incisions to initiate the stromal pocket dissection.

A BFigures 13A and B: Intacs glide blade handle with symmetric glide

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Intacs ForcepsThe forceps is made of titanium and has notched tips that match the shape of Intacs segment (Figure 14). It felicitates easy removal of the segment from the carrier. It uses the same geometric arc action of the tunnel dissector to insert the Intacs in the stromal pocket. The forceps are designed so that they can be used with either hand.

A BFigures 14A and B: Intacs forceps

Intacs Corneal SeparatorThe separator is made up of titanium and used to dissect the stromal tunnel before insertion of the Intacs is commenced. They are available as a set to be used for either channel (Figure 15).

A BFigures 15A and B: Intacs corneal separator

Zone MarkerMade up of titanium, zone marker with cross hairs is used to mark the geometric center of the cornea (Figure 16).

Figure 16: Zone marker

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Documents

Surgical Instruments Brothers Jaypeepostgraduatebooks.jaypeeapps.com/pdf/Opthalmology/...in various textbooks and two textbooks and 4 educational books and manuals. He has received