a. Rigorous adherence to recommended procedures for cleaning and sterilizing surgical instruments should never be circumvented to save time or money.

b. Inventory of instruments should be sufficient to meet surgical volumes and to provide adequate time for completion of cleaning and sterilization.

c. Flash sterilization is designed to manage unanticipated, urgent needs for instruments. Flash sterilization should not be used to save time or as a substitute for sufficient instrument inventory.

a. Instruments should be wiped with a dampened lintfree cloth and flushed and/or immersed in sterile water in the operating room (OR) immediately following use, in strict accordance with manufacturer's DFU for each instrument.23,24 Sterile water baths used for cleaning or soaking soiled instruments should be kept in areas removed from the operative field and removed from sites that maintain instruments needed to complete the surgical procedure.

b. The DFU for some reused cannulated instrument specify the solution, volumes, and frequency for flushing of each lumen. Flushing should be completed as specified in the OR or in the decontamination area.

4. Whether they are used, instruments opened for a procedure should be transported from the OR in a closed container to the decontamination area, where cleaning should be completed immediately.

5. Disposable cannulas and tubing should be used whenever possible, and they should be discarded after each use. These devices are sold without a DFU for cleaning, and thorough cleaning is difficult to achieve and validate.
 
6. Devices labeled for single use only should not be reused single-use devices do not include instructions for reuse or reprocessing. The FDA actively regulates third-party and hospital reprocessors of single-use devices according to FDA guidance.

8. The importance of enzymatic detergents for cleaning soiled intraocular instruments has not been established. Inappropriate use and incomplete rinsing of enzymatic detergents have been associated with outbreaks of TASS.16 If the DFU does not prohibit the use of a detergent and if a detergent is used a. Care should be taken to ensure instructions for proper dilution, outdate, and disposal are followed. The cleaning solution should be mixed with measured amounts of water and detergent (ie, not mixed with estimated volumes), according to the detergent's DFU.23,24,28 b. Following cleaning with detergents, with or without the use of an ultrasonic cleaner, instruments should be thoroughly rinsed with copious volumes of water to ensure removal of all detergent. If rinse volumes are specified by the detergent manufacturer's DFU or by the equipment manufacturer's DFU, they should be considered minimum volumes. Use of tap water for rinsing and for removal of detergent should be compatible with the manufacturer's DFU for the detergent and for the equipment. The final rinse should be with sterile distilled or sterile ionized water.

9. If an ultrasonic cleaner is used

a. Ensure that gross soil has been removed prior to placement in the ultrasonic cleaner.

b. Check the manufacturer's DFU of instruments to identify instruments that should not be subjected to ultrasonic cleaning.

c. An ultrasonic unit designated for cleaning medical instruments should be used.

d. Validation of functioning, degassing, and preventive maintenance should be performed as recommended in the ultrasonic cleaner's DFU.

e. Ultrasonic machines must be emptied, cleaned, disinfected, rinsed, and dried at least daily and preferably after each use.17,18,33 Unless specified otherwise by the manufacturer, cleaning should be performed with an EPA-registered, facility-approved disinfectant and followed by sterile or tap water rinse sufficient to fully remove the cleaning agent. If not contraindicated by the ultrasonic cleaner's manufacturer, final rinse with 70% to 90% ethyl or isopropyl alcohol is recommended when feasible and unassociated with risk for fire. The machine should be dried completely with a lint-free cloth.

b. Cleaning tools such as syringes and brushes should be discarded after each use. If brushes are reused, they should be designed for reuse and they should be cleaned and high-level disinfected or sterilized, preferably after each use, or at least once daily.

c. Cleaning solutions should be discarded after each use.

d. When flushing is used as part of a cleaning technique, the effluent should be discharged into a sink or separate basin so the fluid is not reused. Discharge of the effluent should be completed to minimize splash and aerosolization.

11. Rinsing

a. Follow the manufacturer's DFU for selecting the appropriate type of rinse water for equipment.

b. Unless otherwise specified by the manufacturer's DFU, sterile distilled or sterile deionized water should be used for the final rinse of instruments.

c. Rinsing should provide flow of water through and/or over instruments, with effluent discarded as it is used so only debris-free water is used for rinsing.

d. Agitation in a basin of water should not be used as a final rinse.

12. Following thorough rinsing, instruments with lumens should be dried with forced or compressed air.

a. Compressed air should be filtered and free of oil and water.

b. Instruments with lumens should be fully dried.

13. For: phacoemulsifier handpiece, irrigator/aspirator, irrigator/aspirator tips, and inserters

a. Flush phacoemulsifier handpiece with balanced saline solution prior to removing from the operative field.

b. Wipe each instrument with a lint-free cloth and place immediately in a bath of sterile water. Remove from the operative field and remove from sites that maintain instruments needed for completion of the surgical procedure, in strict accordance with the manufacturer's DFU for each piece of equipment. To avoid introduction of water or reintroduction of gross soil to the operative field, the sterile water bath should be clearly separated from the operative field.