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Spring-action Apparatus for Fixation of Eyeball (SAFE): A novel, cost-

effective yet simple device for ophthalmic wet-lab training

Article  in  British Journal of Ophthalmology · July 2016

DOI: 10.1136/bjophthalmol-2015-308330

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BJO Online First, published on July 26, 2016 as 10.1136/bjophthalmol-2015-308330
▸ Additional material is
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1 Apparatus for Fixation of Eyeball (SAFE)’ is a robust,
Department of Cornea and
Refractive Services, Aravind Eye
Hospital and Postgraduate
Institute of Ophthalmology,
Pondicherry, India
2 generates vacuum and enables reliable fixation of a
Department of Vitreo-Retina
Services, Aravind Eye Hospital
and Postgraduate Institute of
Ophthalmology, Pondicherry,
India
3
Aravind Eye Hospital and
Postgraduate Institute of
Ophthalmology, Pondicherry,
India
4
Instrument Maintenance
Department, Aravind Eye
Hospital and Postgraduate
Institute of Ophthalmology,
Pondicherry, India
5
Glaucoma Services, Aravind
Eye Hospital and Postgraduate
Institute of Ophthalmology,
Pondicherry, India
Correspondence to
Dr Seema Ramakrishnan,
Department of Cornea and
Refractive Services, Aravind Eye
Hospital and Postgraduate
Institute of Ophthalmology,
Cuddalore Main Road,
Thavalakuppam, Pondicherry
605007, India;
drseemar@gmail.com
Received 4 January 2016
Revised 17 June 2016
Accepted 6 July 2016
To cite: Ramakrishnan S,
Baskaran P, Fazal R, et al.
Br J Ophthalmol Published
Online First: [ please include
Day Month Year]
doi:10.1136/bjophthalmol-
2015-308330
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Innovations
Spring-action Apparatus for Fixation of Eyeball
(SAFE): a novel, cost-effective yet simple device
for ophthalmic wet-lab training
Seema Ramakrishnan,1 Prabu Baskaran,2 Romana Fazal,3
Syed Mohammad Sulaiman,4 Tiruvengada Krishnan,1 Rengaraj Venkatesh5
ABSTRACT
Achieving a formed and firm eyeball which is stably fixed
in a holding device is a major challenge of surgical wet-
lab training. Our innovation, the ‘Spring-action
simple and economical device to solve this problem.
It consists of a hollow iron cylinder to which a spring-
action syringe is attached. The spring-action syringe
human or animal cadaveric eye on the iron cylinder. The
rise in intraocular pressure due to vacuum fixation can
be varied as per need or nature of surgery being
practised. A mask-fixed version of this device is also
designed to train surgeons for appropriate hand
positioning. An experienced surgeon performed various
surgeries including manual small incision cataract surgery
(MSICS), phacoemulsification, laser in situ keratomileusis
(LASIK), femtosecond LASIK docking, Descemet’s
stripping endothelial keratoplasty, deep anterior lamellar
keratoplasty, penetrating keratoplasty and trabeculectomy
on this device, while a trainee surgeon practised MSICS
and wound suturing. Skill-appropriate comfort level was
much higher with SAFE than with conventional globe
holders for both surgeons. Due to its stability, pressure
adjustability, portability, cost-efficiency and simplicity, we
recommend SAFE as the basic equipment for every wet lab.
INTRODUCTION
The WHO estimates that currently 39 million
people are blind globally and that this number is
set to increase to 76 million by 2020 if no major
interventions take place.1 India has nine ophthal-
mologists per million population, which is woefully
inadequate for combating national challenges.2 It
becomes imperative to train young ophthalmolo-
gists to meet this increasing demand.
Ophthalmic surgical training has evolved greatly
from animal,3–5 hybrid6 7 and artificial8 9 practice
eye models to virtual reality simulators10–12 and
computer-based learning.13 Despite spending mil-
lions of dollars for simulators that circumvent wet
labs, surgical skill learning on animal or human
cadaveric eyes is still considered the closest
approximation to real surgery, being particularly
useful in low/middle-income countries with finan-
cial constraints.
Conventional globe holders are hollow metal or
plastic cylindrical devices on which cadaveric prac-
tice eyes are fixed with wet cotton pieces7 or
rubber band.5 Such devices have two major draw-
backs: first, the eyeball keeps destabilising due to
lack of a firm hold; second, the cadaveric globe
Ramakrishnan S, et al. Br J Ophthalmol 2016;0:1–5. doi:10.1136/bjophthalmol-2015-308330
tends to collapse due to low intraocular pressure
(IOP). Collapsed globes have to be formed by
injecting saline repeatedly into the vitreous cavity
either through the pars plana or through the optic
nerve stump.14 Attempting to acquire microsurgical
skills in a constantly collapsing chamber of a ‘refus-
ing to stay put’ eye is a nightmare for every surgical
novice and a nuisance even for experienced sur-
geons trying newer surgical techniques.
We describe herein a novel device developed at
our institute, the Spring-action Apparatus for
Fixation of Eyeball (SAFE), constructed out of
inexpensive everyday use materials, that tries to
improvise on previous globe-holding designs.
DESIGN
The prototype design consists of a hollow iron cylin-
der measuring 27 mm in height and 18 mm in
internal diameter. The cylinder is closed at the base
and has a small opening in its wall. This opening
engages the tip of a disposable 5 mL spring-action
syringe (figure 1A). Being spring action, the piston,
once pressed and left, automatically returns to its
original position sucking air into the barrel. When
the eyeball is placed over the device, the spring-
action syringe draws the eyeball into the cylinder
due to the suction generated. The volume of initial
displacement of the piston is proportional to the
IOP rise in the fixed eyeball. Progressively increasing
IOP ranging from 10 to over 60 mm Hg can be gen-
erated (figure 1C, D). This device fixes both human
and animal eyes (goat, sheep and pig eyes) either at
or just behind the equator (figure 2). The periocular
fat or adnexal tissues need not be removed as they
provide a snug fit. A range of five cylinders with
internal diameter from 17 to 19 mm (gradation of
0.5 mm) was manufactured, though the 18 mm
prototype was found suitable for most eyeballs.
Following ethics committee approval for use of
cadaveric eyes, the prototype was used to perform
manual small incision cataract surgery (MSICS), pha-
coemulsification, laser in situ keratomileusis (LASIK),
femtosecond-LASIK docking, Descemet’s stripping
endothelial keratoplasty (DSEK), deep anterior lamel-
lar keratoplasty (DALK), penetrating keratoplasty and
trabeculectomy by an experienced surgeon. A trainee
surgeon performed various steps of MSICS, phacoe-
mulsification and wound suturing (table 1).
Skill-appropriate comfort level for both surgeons was
much higher with SAFE than with conventional
globe holders (see online supplementary video).
Initial practice was done by placing the device on a
styrofoam sheet with a circular central gutter that
1
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Innovations

Figure 1 (A) Prototype Spring-action Apparatus for Fixation of Eyeball (SAFE) device showing two components, the iron cylinder and the
detachable spring-action syringe affixed. Arrow shows the location of the spring between the flange of the syringe barrel and the flange of the
piston. (B) Modified SAFE device showing the mask-affixed version of the device with an eyeball mounted on it. (C) Perkin’s tonometry being
performed over the fixed eyeball. (D) Confirmation of high induced intraocular pressure by Schiotz tonometer.

Figure 2 (A) Collapsed globe before

fixation. (B) Initiation of suction: white
arrow shows spring-action piston being
manually pushed; black arrow shows
piston being displaced forward within
the syringe barrel. (C) Activation of
suction: piston is released, and it
automatically returns back due to
spring action. White arrow shows
backward piston displacement. Note
that the originally collapsed globe is
formed well without any intravitreal
injection of saline or balanced salt
solution. (D) Fixed eyeball resists
gravity on inverting the device.

snugly fit the base of the SAFE (figure 1A). Later modification DISCUSSION
incorporated the device into the eye aperture of a human face mask Stability and firmness of practice eyeball are vital for wet-lab train-
for appropriate hand positioning during surgery (figure 1B). A ing. Conventional eyeball holders offer no reliable fixating mech-
mask offers better overall device stability than a trial head which has anism. Various synthetic,8 semisynthetic14 and biological eye
a rounded base that may destabilise while practising surgical steps. models6 7 have been described for surgical practice, but their use is
2 Ramakrishnan S, et al. Br J Ophthalmol 2016;0:1–5. doi:10.1136/bjophthalmol-2015-308330
Ramakrishnan S, et al. Br J Ophthalmol 2016;0:1–5. doi:10.1136/bjophthalmol-2015-308330

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Table 1 Procedurewise efficiency of the SAFE
Procedures Total fixation loss* Partial fixation loss† Comments

Procedures done by experienced surgeon

MSICS None of 5 eyes None of 5 eyes All human eyes.
Phacoemulsification None of 10 eyes None of 10 eyes All goat eyes with human nucleus implanted.
Microkeratome-assisted LASIK flap-making None of 10 eyes None of 10 eyes Three human and seven goat eyes.
Femtosecond-assisted LASIK flap-making None of 10 eyes None of 10 eyes Three human and seven goat eyes.
DSEK donor dissection None of 8 eyes 5 of 8 eyes All human eyes; refixation is not mandatory with partial
fixation loss, but can be easily achieved in closed chamber procedures by the
SAFE syringe push and release manoeuvre.
DSEK lamella transplantation into host None of 8 eyes None of 8 eyes All human eyes
DALK None of 5 eyes 2 of 5 eyes All human eyes; simple closed chamber refixation on the SAFE can be done if necessary.
Penetrating keratoplasty None of 5 eyes None of 5 eyes All human eyes.
No fixation loss, either partial or total.
Caution: In case of open-sky or non-closed chamber techniques such as penetrating keratoplasty, we experimentally simulated
loss of fixation to note the effects of refixation. Refixation mimicked an expulsive choroidal haemorrhage in an
open-sky setting and severe positive pressure in a partially sutured graft. This effect may be used to
familiarise trainees with such situations.
Trabeculectomy None of 5 eyes None of 5 eyes All human eyes.
Procedures done by novice surgeon
MSICS None of 8 eyes None of 8 eyes All human eyes.
Suturing None of 8 eyes None of 8 eyes All human eyes.
Phacoemulsification None of 10 eyes None of 10 eyes All goat eyes with human nucleus implanted.
*Total fixation loss indicates the practice eyeball losing fixation completely from the device such that the procedure cannot be completed without refixation of the globe.
†Partial fixation loss indicates the SAFE losing grip partially on the practice eyeball after manipulation. Procedure may be still completed without refixation of the globe, although the globe can always be refixed by simply repeating the SAFE syringe push
and release manoeuvre.
DALK, deep anterior lamellar keratoplasty; DSEK, Descemet’s stripping endothelial keratoplasty; LASIK, laser in situ keratomileusis; MSICS, manual small incision cataract surgery; SAFE, Spring-action Apparatus for Fixation of Eyeball.

Innovations
3
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Innovations

Table 2 Concise summary of literature on eyeball-fixating devices

Stability of Stability of
globe device on
within operating Hand
Device Year Design device Manoeuvrability of globe surface positioning Portability Affordability

Styrofoam or – Cadaveric eye stabilised with pins or + + + ++ +++ +++

plastic head rubber bands
Zirm18 1990 Elaborate device with mask + + +++ +++ ++ ++
incorporating artificial orbit, Mask gives
connecting tubes and red reflector excellent stability
plate on surfaces
Porrello et al19 1999 Multiple elements: ++ + ++ ++ ++ +++
plexiglass bulb with PVC screw, nut Manikin head Bulky apparatus
and bolt elements fixed on manikin with rounded
head base gives
average stability
Otto15 2005 Multiple elements: styrofoam manikin +++ ++ ++ +++ + +
head fitted with plastic funnel holder Vacuum No automatic refixation Manikin head Needs operating
with multiple plastic tubes attached to gives mechanism with rounded room set-up
a suction adapter connected to excellent base gives with vacuum
wall-mounted operating room vacuum stability average stability unit
unit
Mohammadi 2011 Complex apparatus involving cup, +++ +++ +++ + + +
et al16 suction tube, heavy ballast and Vacuum Heavy ballast assists automatic Inherently heavy No face form Automated
adjustable aperture, along with gives repositioning. apparatus vacuum unit
voluminous vacuum system; no face excellent needed
form stability
SAFE: our 2015 Minimal elements: iron cylinder with +++ ++ +++ +++ +++ +++
device detachable spring-action syringe Vacuum No automatic refixation Mask-fixed
optionally fitted to a face mask gives mechanism, but simple release version gives
excellent and reapplication of vacuum excellent stability
stability can reposition the globe on surfaces
+poor, ++good, +++excellent.
PVC, polyvinyl chloride; SAFE, Spring-action Apparatus for Fixation of Eyeball.

Figure 3 (A) Entire globe being lifted out of a conventional globe holder (along with cotton rolls used for fixation) by the suction ring used for
microkeratome pass. (B) Globe firmly fixed to the Spring-action Apparatus for Fixation of Eyeball (SAFE) resists vacuum-assisted displacement by
suction ring. (C) SAFE replaces an artificial anterior chamber for practice of lamellar corneal dissection in Descemet’s stripping endothelial
keratoplasty. SAFE being held in the non-dominant hand akin to an artificial anterior chamber.

limited without an efficient stabilising device. The use of vacuum
for fixing eyeballs has efficiently solved this problem. The Otto15
and Mohammadi16 devices use automated vacuum machines for
globe stabilisation and are inherently expensive and less portable,
whereas the SAFE uses minimal elements with a simple spring-
action syringe to generate the desired vacuum reproducibly,
making it highly cost-effective and portable. A commercially avail-
able product, the Mandell device, uses a conventional syringe con-
nected to a plastic tube attached to the globe holder.17 The effort
needed to pull the piston of a conventional syringe in order to gen-
erate adequate vacuum is significant. This effort is virtually elimi-
nated by the spring-action syringe of the SAFE. Also, direct
connection of the syringe tip to the cylinder eliminates additional
tubing. Table 2 summarises and compares available literature on
various globe-fixation devices.
4 Ramakrishnan S, et al. Br J Ophthalmol 2016;0:1–5. doi:10.1136/bjophthalmol-2015-308330
Our device gives excellent performance, especially during the
practice of microkeratome pass (for LASIK or automated DSEK)
and lamellar corneal dissection (for DALK and manual DSEK).
Contrary to conventional devices that allow the globe to be
easily lifted out of the holder by the suction ring, the SAFE pre-
vents any globe dislodgement and facilitates smooth microkera-
tome pass (figure 3A, B). Lamellar corneal dissection, probably
the most globe-destabilising procedure in the wet lab, is per-
formed smoothly on the SAFE due to its dependable hold. In
fact, the device has the potential to eliminate the use of an artifi-
cial anterior chamber (AAC) for DSEK donor preparation.
Usually, this step is performed by mounting a donor corneoscl-
eral button on an AAC which poses added expenditure to
wet-lab practice. Instead, using a whole globe on the SAFE pro-
vides an identical experience during training. The original
 Downloaded from http://bjo.bmj.com/ on August 3, 2016 - Published by group.bmj.com
maskless version of the SAFE can even be held in the non-
dominant hand such as the AAC while performing dissection
with the dominant hand during manual DSEK, as is preferred
by many surgeons including the author (figure 3C).
In conclusion, we recommend this simple, robust and
low-cost device as the basic equipment in wet labs. Multiple
models can be assembled, one for each practice station, so that
multiple trainees can simultaneously practice surgery, saving
both time and money.
Acknowledgements The authors acknowledge the participation of Dr Prashanth
Gireesh and Ms S Vinitha, in addition to RF, one of the coauthors, who appear in
the online supplementary video submitted to BJO.
Competing interests None declared.
Ethics approval Institutional Ethics Committee, Aravind Medical Research
Foundation, No. 1 Anna Nagar, Madurai-625020, Tamil Nadu, India.
Provenance and peer review Not commissioned; externally peer reviewed.
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 Downloaded from http://bjo.bmj.com/ on August 3, 2016 - Published by group.bmj.com

Spring-action Apparatus for Fixation of

Eyeball (SAFE): a novel, cost-effective yet
simple device for ophthalmic wet-lab training
Seema Ramakrishnan, Prabu Baskaran, Romana Fazal, Syed
Mohammad Sulaiman, Tiruvengada Krishnan and Rengaraj Venkatesh

Br J Ophthalmol published online July 26, 2016

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