Incision and curettage of chalazion

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• bleeding and lid bruising
• swelling that may persist for 2 to 3 weeks
• recurrence at the same site or a new chalazion
• infection
• damage to lash roots or lid margin notch if the lesion is at the margin
• damage to the punctum or canaliculus for a lesion near the punctum
• tissue sent for HPE, and a wider lid excision if it turns out to be a tumour

Pre-operative details for this operation

1. Eye, lid and siteRight upper lidRight lower lidLeft upper lidLeft lower lidalso medial / central / lateral third, and distance from the punctum
2. Number of chalazia on this lidsingle / multiple, size in mm
3. Duration and previous treatmenthot fomentation, antibiotic drops, steroid injection, earlier I&C at the same site
4. Recurrent at the same siteNoYes: HPE planned
5. Where the lesion pointsConjunctival sideSkin sideLid margin
6. Visual acuity of both eyesrecord before any lid procedure
7. Associated lid diseaseblepharitis, acne rosacea, seborrhoeic dermatitis
8. Operated eye markedYes

Anaesthesia and position

1. Topical anaesthesiadrug and number of drops, e.g. amethocaine 1% or lignocaine drops
2. Local infiltrationlignocaine 2% with adrenaline, volume, injected at the tarsal border and on either side of the lesion
3. Other anaesthesiaif not local, state the type and the reason
4. PositionSupine

Operative findings

1. Size of the chalazionin mm
2. ContentsGelatinous granulation tissuePus (infected)Firm tissue with no gelatinous material
3. ExtensionConfined to tarsusThrough tarsus into orbicularisLoculated
4. Cyst wallThinThick fibrous
5. Anything suspicious of malignancyNoYes: tissue sent for HPE

Procedure (steps)

1. Painting and drapingantiseptic used
2. Chalazion clamp appliedring on the conjunctival side with the lesion in its centre, plate on the skin; lid everted
3. IncisionVertical, conjunctival sideHorizontal, skin side, about 3 mm from the lid marginblade used (No. 11), length; conjunctival incision runs along the gland
4. Curettagecurette / chalazion scoop size; all granulation tissue removed; loculi and pockets looked for
5. Cyst wallNot excisedExcised with forceps and scissors (recurrent)
6. Cavity cautery (if done)Not doneCarbolic acid, neutralised with methylated spirit
7. Cavity cleanedswabbed dry; washed with saline if needed
8. Clamp released and haemostasispressure for how long; bleeding stopped

Closure, drains and dressing

1. SuturesNone (conjunctival incision)Skin sutures: material and size
2. Antibiotic eye ointmentdrug instilled in the conjunctival sac
3. PadNo padPad and bandageif pad, for how many hours

Specimens and implants

1. Curetted tissue for HPESent (recurrent / firm / elderly patient)Not sentcontainer, fixative, requisition with lid and site

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Pad removaltime, if a pad was applied
2. Antibiotic eye ointment or dropsdrug, frequency, duration (about a week)
3. Hot fomentationfrom the next day, frequency
4. Oral analgesicdrug, dose, days
5. Warning about residual swellinga small lump may stay for 2 to 3 weeks
6. HPE report follow-update to review the report, if tissue was sent
7. Reviewday and reason to return early: pain, spreading redness, reduced vision

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery