OT notes · Ophthalmology

External dacryocystorhinostomy (DCR)

Usual anaesthesia
General anaesthesia with controlled hypotension; local anaesthetic with adrenaline infiltrated at the site
Position
Supine, head-up
Setting
elective

Operative note template for external dacryocystorhinostomy with sutured mucosal flaps and silicone intubation, with a filled example for primary acquired nasolacrimal duct obstruction with a mucocoele.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

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 from the nose, early or up to a week later
  • visible scar at the side of the nose (small chance)
  • failure, with watering continuing, needing further surgery
  • wound or soft-tissue infection
  • silicone tube coming out early or rubbing the eye
  • watering may take months to settle
  • blocked canaliculi found at surgery may need a bypass tube later

Pre-operative details for this operation

  1. SideRightLeftmarked on the side of the nose
  2. SymptomsWatering (flow symptoms)Discharge / mucocoele / dacryocystitis (volume symptoms)duration; episodes of acute dacryocystitis
  3. Syringing and probingregurgitation from same / opposite punctum, hard or soft stop, level of block (canalicular / common canalicular / nasolacrimal duct)
  4. Nasal examinationseptal deviation, polyps, rhinitis
  5. Imaging (only if atypical)CT if swelling above the medial canthal tendon, globe displacement or a hard mass
  6. Antiplatelets / anticoagulantswhen stopped; INR if on warfarin; bridging plan

Anaesthesia and position

  1. AnaesthesiaGeneral with controlled hypotensionLocal anaesthesia with sedationlocal infiltration: drug, strength, adrenaline, volume
  2. PositionSupine, head-up
  3. Nasal vasoconstrictioncotton pledgets / cotton-tips with adrenaline placed high and anterior in the nose: number and strength; removed and counted at the end

Operative findings

  1. Lacrimal sacsize, mucocoele / pus / dacryolith / mass; wall thickness
  2. Common canalicular openingseen and patent / membrane / stenosed
  3. Anterior ethmoidal cellspresent between sac and nose / not present
  4. Nasal mucosahealthy / inflamed / thin

Procedure (steps)

  1. Skin incisionalong the flat side of the nose, medial to the medial canthus; length; blade
  2. Medial canthal tendon and periosteumtendon identified; periosteum divided along the anterior lacrimal crest and reflected
  3. Sac displaced laterally from the fossamaxillolacrimal suture exposed
  4. Bony rhinostomyinfracture at the suture; rongeur used; size in mm; bone at the level of the common canaliculus removed; L-shaped extension
  5. Anterior ethmoidectomy / trimming of posterior lacrimal crestDoneNot needed
  6. Sac openedlacrimal probe through the lower canaliculus tents the sac; entry at the sac/duct junction with a No. 11 blade; opened fundus to duct like a book
  7. Nasal mucosa incisedH-shaped incision about 3 mm in front of the middle turbinate arch, anterior and posterior flaps
  8. Posterior flaps suturedSutured, continuous locked absorbable 6-0Excised / not sutured
  9. Silicone intubationBicanalicular silicone stent placedNo stent (reason)how secured in the nose (knot, ligature)
  10. Anterior flaps suturedsuspended to orbicularis; number of sutures; material
  11. Haemostasismethod; pledgets removed and counted

Closure, drains and dressing

  1. Orbicularisclosed with the anterior flap suspending sutures
  2. SkinHorizontal mattressInterruptedSubcuticularsuture material and size; edges kept flat, not everted
  3. Nasal packNonePlaced (type, to be removed when)
  4. Dressingtype

Specimens and implants

  1. Sac tissue or massNot sentSent for HPE (reason)
  2. Pus / sac contentsNot sentSent for culture
  3. Silicone stentmake, size, lot number; planned removal date

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. Watch for nosebleedhead-up; check the nose and dressing; inform if bleeding continues
  2. No hot drinksfor 12 hours after surgery
  3. No nose blowingfor 1 week
  4. Antibioticsoral course only if gross infection, soft-tissue infection or bilateral surgery; drug and dose
  5. Eye and nasal dropsdrug and frequency, if ordered
  6. Stitch removalskin sutures at 7 to 10 days
  7. Stent removalat 3 to 6 weeks; date written on the discharge card
  8. Expectationwatering may keep improving for months as swelling settles

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

Worked example

Fictional case: Mrs. L.M., 52 years, watering and sticky discharge from the left eye for 2 years, mucocoele of the left lacrimal sac, regurgitation of mucopus on pressure over the sac, syringing blocked with reflux from the opposite punctum and a hard stop.

Case details

Date: 06/05/2026. Elective. OT 4.

Induction 10:10. Incision 10:25. Skin closure completed 11:30.

Surgeon: Dr A. (3rd-year resident, Ophthalmology). Consultant: Dr C., present and assisting.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Left primary acquired nasolacrimal duct obstruction with mucocoele. Hard stop on probing, so canaliculi patent. No swelling above the medial canthal tendon, no globe displacement; CT not needed.

Nasal examination: mild septal deviation to the right, left side roomy.

Aspirin stopped 2 weeks before surgery after physician clearance. Not on warfarin.

Consent: general and procedure-specific consent taken in Tamil, including nosebleed, scar, failure and tube. Left side marked. WHO checklist sign in and time out done.

Anaesthesia and position

General anaesthesia with controlled hypotension. Supine, head-up.

Three cotton-tips moistened with adrenaline 1:1000 placed high and anterior in the left nasal cavity. Incision site infiltrated with local anaesthetic containing adrenaline, as charted by the anaesthetist.

Parts painted with povidone-iodine and draped, both eyes protected.

Procedure

Skin incision 12 mm along the flat side of the nose with a No. 15 blade. Medial canthal tendon identified.

Periosteum divided along the anterior lacrimal crest and reflected with a periosteal elevator. Sac displaced laterally; mucopus seen at the medial canthus on pressure.

Maxillolacrimal suture infractured and a large L-shaped bony rhinostomy made with a small up-cutting rongeur, about 12 x 15 mm, with bone alongside the common canaliculus removed. Anterior ethmoidal cells removed and posterior lacrimal crest trimmed.

Sac tented with a 00 probe through the lower canaliculus and entered at the sac/duct junction with a No. 11 blade, then opened from fundus to duct with spring scissors. Sac enlarged with mucopus, no dacryolith, no mass. Common canalicular opening seen and patent.

H-shaped incision in the nasal mucosa about 3 mm in front of the middle turbinate arch, making anterior and posterior flaps.

Posterior sac and nasal flaps sutured with continuous locked 6-0 absorbable suture.

Bicanalicular silicone stent passed through both canaliculi, knot reinforced with a 2-0 silk ligature, and ends drawn into the nose.

Anterior sac and nasal flaps sutured and suspended from the orbicularis with three sutures.

Cotton-tips removed from the nose and counted (3 in, 3 out). Haemostasis confirmed.

Closure

Orbicularis closed with the suspending sutures. Skin closed with horizontal mattress sutures, edges flat. No nasal pack. Light dressing.

Specimens and implants

No tissue sent. Mucopus not sent for culture.

Silicone lacrimal intubation set: make ________, lot no. ________. Removal planned at 4 weeks.

End of procedure

Estimated blood loss 50 ml. No transfusion.

Mop, needle, instrument and nasal cotton-tip count correct, confirmed by scrub nurse.

No intra-operative complications.

Shifted to recovery in stable condition. Pulse 82/min, BP 124/78 mmHg.

Post-op orders

Head-up. Watch the nose and dressing for bleeding, inform if continuous.

No hot drinks for 12 hours. No nose blowing for 1 week.

No oral antibiotic needed: no gross infection, single side.

Skin sutures to be removed on day 7 to 10. Stent removal in OPD at 4 weeks.

Explain that watering can keep improving for months.

Signature

Dr A., JR-3, Ophthalmology. Reg. no. ________. 06/05/2026, 11:45.

Must document for this operation

  • Level of block found on syringing and probing, and the state of the common canalicular opening at surgery. Canalicular blocks have a poorer prognosis, and the next surgeon needs this before any redo or bypass tube.
  • Size of the rhinostomy and whether anterior ethmoidal cells were removed. A small ostium or leftover cells is a common reason for failure, and a redo surgeon plans from this entry.
  • How the flaps were handled: sutured, excised or left. It explains the healing pattern seen on nasal endoscopy later.
  • Silicone stent placed, how it was secured, and when it must come out. The stent is meant to come out at 3 to 6 weeks, so the removal date must be on record for the OPD team.
  • Number of nasal pledgets or cotton-tips placed and removed. A retained nasal pack is a preventable error and the count proves it was avoided.
  • Sac findings such as dacryolith or a mass, and whether tissue went for HPE. A hard or unusual sac needs a tissue diagnosis, and the note shows whether one was looked for.

Common mistakes in these notes

  • Writing 'DCR done' with no rhinostomy size or flap details.
  • Not counting nasal pledgets in and out.
  • No stent removal date on the note or discharge card.
  • Not writing the level of block found on probing.
  • Leaving out an abnormal-looking sac wall without sending it for HPE.

Indian practice and paperwork

  • NABH expects the operative note to be written before the patient is moved out of recovery, and post-op care to follow a written plan. Put the stent removal date in that plan. (NABH 5th ed., COP.14(e) and (f))

Sources

  • Clinical Atlas of Procedures in Ophthalmic and Oculofacial Surgery, Ch 98, External Dacryocystorhinostomy (Verity DH, Rose GE), pp. 1021-1032.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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