Ophthalmic Surgical Instruments Jeewan S Titiyal, Rajesh Sinha, Vijay Kumar Sharma
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Basic Instruments in Ophthalmic SurgeryChapter 1

Sandeep Gupta,
Vijay K Sharma
 
INTRODUCTION
Ophthalmology deals with precision surgery of a relatively small and highly delicate and specialized structure. The instruments used in ophthalmic surgeries hence, need to be precise, efficient, light weight and well controlled for a given surgical task. Ophthalmology instruments underwent a big change with the advent of the operating microscope, with the need for lighter instruments with non reflective surfaces becoming the norm. Ophthalmic instruments hence came to be made of titanium alloys, which is lighter than steel, corrosion resistant and has a matte finish. However, a major drawback is that titanium alloys cannot maintain sharp edges. Following is a brief description of the common and basic instruments used in majority of ophthalmological surgeries.
 
LID SPECULUMS
Speculums are essential for exposure and visualization, in both intraocular and extraocular surgeries. A variety of speculums are available, however, the most commonly used are Barraquer Wire Speculum and the self-retaining speculum with screw. Speculums with solid blades are heavier and are mainly used in extraocular surgeries like strabismus (Figure 1).
Wire speculum is most commonly used speculum for adequate exposure of eye during any ocular surgery and retrieval of globe/ cornea. 2It is light weighted with fenestrated blades, puts minimal pressure on the globe, and available in various pediatric (9–14 mm) and adult sizes (16–18 mm). Available in two forms for nasal and temporal approaches.
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Figures 1A to C: (A) Barraquer wire speculum; (B) Lieberman self-retaining speculum with screw; (C) Speculum with solid blades
 
Uses
Eye speculums are used to keep the lids apart during:
  • Any intraocular operation such as cataract, vitreoretinal and glaucoma surgery
  • Any extraocular surgery, e.g. squint surgery, pterygium surgery
  • Enucleation and evisceration surgery
  • Removal of conjunctival and corneal foreign bodies
  • Cauterization of corneal ulcer
  • Examination of the eye in a patient with blepharospasm.
 
FORCEPS
 
Kelman-McPherson Forceps
Devised by Charles D Kelman (1930–2004), these are nontoothed forceps with smooth jaws with an angled 5 mm long platform, ideal for tying 8-0 to 11-0 sutures. It is a nontoothed forceps with angled jaws and a smooth tying platform (Figure 2).
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Figures 2A and B: Kelman-McPherson forceps
 
Uses
  • To hold and insert polymethyl methacrylate (PMMA) intraocular lens (IOL)
  • For loading foldable IOLs in the cartridge
  • It is used for tying 8-0 to 11-0 sutures
  • It is also useful for holding/tearing the lens capsule tags.
 
Suture Tying Forceps
These are fine and delicate, nontooth catch less forceps, used to hold and tie the fine sutures used in ophthalmic surgeries (Figure 3).
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Figures 3A and B: Suture tying forceps
 
Lim's Corneoscleral Forceps
These are toothed forceps with very fine teeth (1 × 2) at the tip and has a tying platform (Figure 4).
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Figures 4A and B: Lim's corneoscleral forceps
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Uses
These are used to hold the cornea or scleral edge (of incision) for suturing during cataract surgery, glaucoma surgery, repair of corneal and/or scleral tears and penetrating or lamellar keratoplasty.
 
Superior Rectus Holding Forceps
It is toothed forceps (1 × 2 teeth) with an S-shaped double curve near the tip. It is designed to fit the contour of the eyeball. The first angle is at a distance of 7.7 mm from the tip (Figure 5).
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Figures 5A and B: Superior rectus holding forceps
 
Uses
It is used to hold the superior rectus muscle in order to pass the bridle suture for fixing the eyeball during surgery. The eyeball is rotated downwards which is useful in intracapsular cataract extraction, extracapsular cataract extraction, corneal surgeries and glaucoma surgeries.
 
Utrata Capsulorhexis Forceps
It is named after Utrata, a river in the Mazowieckie voivodship on the Plain Lowicko-Błonska in Poland. It has a 12 mm angled curved shaft, of 105 mm length. It is a tissue forcep with angled fine tips which help to puncture and grasp the anterior capsule (Figure 6). It is introduced through main entry wound during cataract surgery. The angled 12 mm shafts with iris stop allow ease of movement in the anterior chamber.
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Figure 6: Utrata capsulorhexis forceps
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Uses
  • It can be used to pick up the anterior capsular flap created by the cystotome needle to complete the capsulorhexis
  • It can be used instead of cystotome needle for capsulorhexis.
 
EYE SCISSORS
 
Straight Scissors
It is a fine pointed scissors with straight sharp cutting blades (Figure 7). It is used to cut conjunctival sutures, eyelashes and muscles.
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Figure 7: Straight scissors
 
Vannas Scissors
These are very fine delicate scissors with small cutting blades kept apart by spring action. They have sharp tips, 7.0 mm blades, 9.0 mm from pivot to tip and 82 mm in length. The blades may be straight or curved (Figure 8).
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Figures 8A and B: Vannas scissors
 
Uses
  • Cutting anterior capsule of the lens in extracapsular surgery and for cutting 10-0 nylon sutures
  • For doing pupillary sphincterotomy
  • For performing iridectomy
  • 6To create the ostium (cutting the trabecular flap) in trabeculectomy
  • For cutting pupillary membrane
  • To cut scleral flap during scleral fixation of IOL.
 
Corneal Scissors or Section Enlarging Scissors
They are fine curved scissors. Their cutting blades are kept apart by spring action. They are available in various shapes and sizes. The universal corneal scissors can be used for both sides while right and left curved corneal scissors are separated for the two sides (Figure 9).
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Figures 9A and B: Corneal scissors
 
Uses
  • These are used to enlarge corneal or corneoscleral incision for conventional intracapsular and extracapsular cataract extraction cataract surgery
  • To enlarge corneal incision in keratoplasty operation
  • To cut the scleral and trabecular tissue in trabeculectomy.
 
Conjunctival Spring Scissors (Westcott's)
They are stout scissors available with straight or curved blades with sharp or blunt tips (Figure 10). The blades are kept apart by spring action.
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Figures 10A and B: Westcott's conjunctival spring scissors
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Uses
They are used as a handy alternative to plain straight and plain curved ringed scissors for cutting and undermining conjunctiva in various operations and to cut sutures.
 
NEEDLE HOLDER
 
Castroviejo-Kalt Needle Holder
1889, French Ophthalmologist Eugene Kalt built this instrument. It has got straight serrated jaws. Its around 5 1/4” (13.5 cm) in length. The upper shank of these needle holders has a flat and broad plate to accommodate the surgeon's thumb (Figure 11). These are available with and without locking device. Kalt needle holder is a commonly used tool in postoperative management of ophthalmologic procedures. The instrument is used to grip the needle in strabismus, lid, or lacrimal operations.
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Figure 11: Castroviejo-Kalt needle holder
 
Arruga Needle Holder
It has a locking mechanism to better stabilize the needle (Figure 12). It is used for extraocular procedures such as lid surgery and passing the bridle sutures under rectus muscles, etc.
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Figure 12: Arruga needle holder
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Barraquer Needle Holder
Named after Dr Ignacio Barraquer, a French ophthalmologist remembered for establishing the Catalan School of Ophthalmology in the “Hospital de la Santa Creu”. The instrument has delicate 9 mm jaws, sharp tips, with or without lock and is 115 mm in length (Figure 13).
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Figures 13A and B: Barraquer needle holder
It is used as needle holders especially in retina surgery (posterior compartment). They are a type of straight needle holders. The jaws of the needle holder are finely serrated to hold the fine needles firmly. Spring type needle holders are used for passing sutures in the conjunctiva, cornea, sclera and extraocular muscles.
 
CALLIPERS
 
Castroviejo Calipers
Designed by Ramón Castroviejo Briones (1904–1987) who was a famous Spanish and American eye surgeon remembered for his achievements in corneal transplantation. Overall length of the instrument is around 3.4 inches. These callipers are a combination of measuring and marking instruments with a thumbscrew to hold tips apart (Figure 14). The caliper measures from 0 to 20 mm with a 1 mm least count and a scale reading on both sides.
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Figure 14: Castroviejo callipers
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Uses
  • To take measurements during squint, ptosis, retinal detachment and pars plana vitrectomy surgery.
  • It is also used to measure corneal diameter and visible horizontal iris diameter.
  • To measure and mark flap location during SFIOL surgery.
 
INSTRUMENT BOX (FIGURE 15)
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Figures 15A and B: Instrument box