BACKGROUND To ensure optimal performance, it is imperative to properly maintain the condition of ophthalmic diamond scalpels. Refractive surgeons are often confronted with conflicting cleaning recommendations from manufacturers. The problem encountered is to maximize cleaning while minimizing trauma to the diamond to maintain its longevity. METHODS The author describes a flexible graded approach to cleaning and maintaining diamond scalpels. The principle of this approach was the development of four successive levels of cleaning based on an increasing risk of trauma to the diamond: Level I--irrigation with distilled water, Level II--hydrogen peroxide or enzyme cleaning, Level III--ultrasonic and detergent cleaning, and Level IV--mechanical styrofoam block cleaning. The protocol was performed prospectively on 50 consecutive radial keratotomy cases, inspecting the blade microscopically after each cleaning step, and determining the level at which cleanliness of the blade was achieved. RESULTS The effectiveness (clean/dirty) of each cleaning level was evaluated by the author and an experienced surgical assistant. The difficulty in accurately measuring the amount of debris and the force necessary to remove it, limited the judgments made to subjective observation. Only 2 of 50 blades were cleaned at Level I, while 41 of 48 at Level III, and 7 of 7 at Level IV. CONCLUSIONS A multi-leveled systematic process for cleaning maintenance appears most effective for maximal performance and longevity of diamond scalpels used for refractive keratotomy surgery.