Cyclocryotherapy / cyclophotocoagulation

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

• pain after the procedure, can be severe after cryotherapy
• rise in eye pressure in the first hours
• inflammation inside the eye
• further loss of vision
• pressure may not come down enough; repeat treatment may be needed
• eye pressure too low (hypotony) and shrinkage of the eye (phthisis)
• bleeding in the front of the eye (hyphaema)
• block-related: bleeding behind the eye, globe perforation (rare)

Pre-operative details for this operation

1. EyeRightLeft
2. DiagnosisNeovascular glaucomaAbsolute glaucomaRefractory glaucoma after failed trabeculectomy / tubeOther secondary glaucoma
3. Visual acuityoperated eye and fellow eye; write PL / no PL clearly
4. IOP before proceduremmHg, method, time; current glaucoma drugs
5. Reason for cyclodestruction over filtering surgerylimited visual potential, failed filtering surgery or tube, low chance of success with filtering surgery, unfit for theatre surgery
6. Previous cyclodestructiondate, type, quadrants already treated
7. Eye markedYes

Anaesthesia and position

1. AnaesthesiaPeribulbar blockRetrobulbar blockGeneral (child / uncooperative)drug, concentration, volume, given by whom
2. Topical anaestheticdrug
3. SpeculumYes

Operative findings

1. Cornea and anterior chamberoedema, hyphaema, depth
2. Irisneovascularisation, sector iridectomy, aniridia
3. Sclerathinning, previous surgery sites, blebs or tubes to avoid
4. Popping sounds during diode treatmentnumber and power at which heard

Procedure (steps)

1. MethodCyclocryotherapyTransscleral diode cyclophotocoagulation (G-probe)Endoscopic cyclophotocoagulation
2. Probe and positioncryo: probe size, distance from limbus in mm, and whether measured to the probe centre or its front edge; diode: footplate edge at limbus
3. Cryo settingstemperature, duration of each freeze, ice-ball seen, slow thaw
4. Diode settingsstarting power (mW), duration (s), power changes, final power
5. Number of applications and quadrants treatedclock hours, e.g. 3 per quadrant in the two inferior quadrants; areas spared
6. IOP at endif measured
7. Medication at endtopical steroid, cycloplegic, antibiotic as used

Closure, drains and dressing

1. Speculum removed
2. PadPad and bandageNo pad

Specimens and implants

1. SpecimensNone

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. IOP checkcheck within the first hours after treatment; treat a rise
2. Painanalgesic drug, dose, frequency; pain is worse after cryotherapy
3. Topical steroide.g. prednisolone acetate 1% four times a day for about 10 days, then taper by inflammation
4. Glaucoma drugscontinue all; stop one by one as IOP allows
5. Cycloplegicif prescribed: drug, frequency
6. Reviewnext day with IOP; repeat treatment is considered only after a few weeks

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