OT notes · Ophthalmology

Manual small incision cataract surgery (SICS) with PCIOL

Usual anaesthesia
Local: peribulbar or sub-Tenon block (topical alone is not enough for the scleral tunnel and bridle suture)
Position
Supine, head stable on a head ring, operating microscope
Setting
elective

Operative note template for manual small incision cataract surgery with posterior chamber IOL, with a filled example for a mature senile cataract done under peribulbar block with a rigid PMMA IOL.

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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

  • posterior capsule rupture and vitreous loss, sometimes needing anterior vitrectomy
  • nucleus or fragments falling into the vitreous, needing a second operation
  • IOL placed in the sulcus or anterior chamber, or not placed at the same sitting
  • infection inside the eye (endophthalmitis)
  • corneal swelling, Descemet's membrane detachment
  • raised eye pressure after surgery
  • iris damage or iridodialysis
  • wound leak needing sutures, astigmatism
  • block-related: bruising, double vision, globe perforation (rare), retrobulbar haemorrhage
  • suprachoroidal (expulsive) haemorrhage (rare)

Pre-operative details for this operation

  1. Eye to be operatedRight eye (RE)Left eye (LE)write in full; mark above the eyebrow of the correct eye
  2. Type of cataract and pupilimmature / mature / hypermature / brunescent; dilated pupil size in mm; pseudoexfoliation; red reflex
  3. Visual acuity and IOPbest-corrected vision, IOP in mmHg, fundus / B-scan if no view
  4. Biometryaxial length, K1/K2, formula used, target refraction, IOL power chosen; re-checked against the lens in OT
  5. Lacrimal sac syringing and adnexapatent / regurgitation; blepharitis treated
  6. Allergy check before intracameral antibioticespecially cephalosporin allergy if cefuroxime is planned
  7. Blood sugar, BP, anticoagulantsvalues on the day; antiplatelet or anticoagulant status

Anaesthesia and position

  1. AnaesthesiaPeribulbar blockSub-Tenon blockRetrobulbar blockGeneral (uncooperative patient)who gave it, drug, strength and volume, time; akinesia achieved
  2. Preparation5% povidone-iodine to conjunctiva and cul-de-sac for 2 to 5 minutes; 5 to 10% to periocular skin; lashes isolated with drape
  3. Speculum and bridle sutureSuperior rectus bridle suture, silk 4-0Lateral rectus bridle (temporal tunnel)No bridle suture

Operative findings

  1. Cataract grade and nucleussoft / moderate / hard / brunescent; nucleus size
  2. Anterior chamber depth and pupil during surgerynormal / shallow; pupil maintained / constricted
  3. Zonulesintact / phacodonesis / dialysis (clock hours)
  4. Posterior capsule at endIntactRent without vitreous lossRent with vitreous losssize and position of any rent, what was done

Procedure (steps)

  1. Conjunctival flapfornix-based, about 7 to 8 mm, site (superior / temporal / superotemporal); light cautery to sclera
  2. Scleral grooveStraightFrownChevronlength about 6 to 7 mm, about 1.5 to 2 mm behind the limbus, 30 to 50% scleral depth; blade used
  3. Sclerocorneal tunnelbevel-up crescent blade, at least 1 to 1.5 mm into clear cornea, side pockets made; any premature entry or buttonhole
  4. Side portposition in clock hours
  5. Capsule stain and viscoelasticTrypan blue usedNo stainOVD used
  6. Anterior chamber entrykeratome size; internal incision extended in the same plane
  7. CapsulotomyContinuous curvilinear capsulorhexis (CCC)Can-opener capsulotomyTriangular (V-shaped) capsulotomysize in mm; relaxing cuts or conversion if CCC too small
  8. HydrodissectionBSS with 27 G cannula; nucleus free and rotating
  9. Nucleus prolapse into the anterior chamberHydroprolapseDialled out with Sinskey hookBimanual with spatula and Sinskey hook
  10. Nucleus deliveryIrrigating vectisViscoexpressionSandwich technique (vectis and Sinskey hook)Simcoe cannula technique
  11. Epinucleus and cortex removalSimcoe cannula via main wound / side port; subincisional cortex removed
  12. IOL implantationRigid PMMA IOL in the bag3-piece IOL in the ciliary sulcusFoldable IOL in the bagtype, optic size, power, A-constant, position; centred
  13. OVD removal and chamber formedOVD aspirated with Simcoe; AC formed with BSS through side port
  14. Intracameral antibioticMoxifloxacinCefuroximeNot givendrug, dose and volume (e.g. moxifloxacin 500 micrograms in 0.1 ml; cefuroxime 1 mg in 0.1 ml after allergy check)

Closure, drains and dressing

  1. WoundSelf-sealing, suturelessSutured with 10-0 nylon (number of sutures)tested for leak
  2. ConjunctivaApposed with cauteryBallooned over wound with subconjunctival injectionSutured
  3. Bridle suture removed
  4. Pad / shieldPressure patch (after peribulbar / retrobulbar block)Pad and shieldShield only

Specimens and implants

  1. IOL detailsmake, model, type (rigid PMMA / foldable), optic size, power in D, A-constant, lot / batch and serial number, expiry; sticker pasted in the note
  2. IOL barcode numbercopy for scheme claims (PM-JAY) and discharge summary
  3. SpecimenNone

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. Padkeep pad and shield till first-day check; do not rub the eye
  2. First post-op reviewnext morning: vision, wound, AC depth and cells, IOL position, IOP
  3. Steroid eye dropsdrug and frequency, tapered over about 6 weeks
  4. Antibiotic eye dropsdrug; commonly 4 times a day for 5 to 7 days
  5. Night shieldfor the first 7 to 10 days
  6. Activityavoid heavy lifting, bending and strenuous work at first
  7. IOP riseif raised on day 1 (often retained OVD): anti-glaucoma drops for a few days
  8. Warning signspain, drop in vision, redness, discharge: come back the same day
  9. Follow-up and glassesreview dates; refraction for glasses after the steroid course

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. S.B., 66 years, mature senile cataract in the right eye, vision hand movements close to face, projection of rays accurate, IOP 16 mmHg, B-scan normal.

Case details

Date: 09/02/2026. Elective. Eye OT 1.

Block given 10:05. Incision 10:15. IOL in 10:32. Pad applied 10:40.

Surgeon: Dr A. (2nd-year resident, Ophthalmology). Consultant: Dr C., present in OT. Block given by Dr A. under supervision.

Scrub nurse: Sr E.

Indication and pre-op

Right eye (RE) mature senile cataract. Pupil dilated to 7 mm. No pseudoexfoliation. Lacrimal sac syringing: patent. Random blood sugar 142 mg/dl, BP 138/84 mmHg.

Biometry (optical): axial length 23.10 mm, K1 43.50 D, K2 44.25 D, SRK/T formula, target -0.25 D. IOL power 21.5 D (rigid PMMA, A-constant 118.0).

Consent: general and procedure-specific consent taken in Hindi, including posterior capsule rupture, dropped nucleus, endophthalmitis and need for glasses after surgery. RE marked above the right eyebrow.

WHO checklist sign in and time out done. Eye, IOL type and power read aloud and checked against the biometry sheet before opening the lens. No cephalosporin allergy.

Anaesthesia and position

Peribulbar block, inferotemporal, 5 ml of lignocaine 1% with bupivacaine 0.375%, no adrenaline. Aspirated before injecting. Akinesia adequate after 10 minutes.

Supine, head on ring. Conjunctival sac and cul-de-sac irrigated with 5% povidone-iodine, left for 3 minutes; lids and skin painted with 10% povidone-iodine. Draped with lashes tucked under the drape. Wire speculum.

Superior rectus bridle suture with silk 4-0.

Procedure

Fornix-based conjunctival flap of 7 mm superiorly. Light wet-field cautery to the sclera.

Frown-shaped scleral groove 6.5 mm long, 2 mm behind the limbus at the centre, about one-third scleral depth, with a No. 15 blade.

Sclerocorneal tunnel made with a bevel-up crescent blade, 1.5 mm into clear cornea, with side pockets. No premature entry, no buttonhole.

Side port at 9 o'clock. Anterior capsule stained with trypan blue. AC filled with viscoelastic (OVD).

AC entered with a 3.2 mm keratome and internal incision extended to the full width of the tunnel.

Continuous curvilinear capsulorhexis of about 6.5 mm.

Hydrodissection with BSS through a 27 G cannula. Upper pole hydroprolapsed; rest of the nucleus dialled into the AC with a Sinskey hook.

OVD injected above and below the nucleus. Nucleus (grade 4, brown) delivered with an irrigating vectis while pulling the bridle suture taut.

Epinucleus and cortex aspirated with a Simcoe cannula; subincisional cortex removed through the side port.

Posterior capsule intact. Bag filled with OVD. Rigid single-piece PMMA IOL, 6 mm optic, 21.5 D, placed in the capsular bag. Well centred.

OVD aspirated with the Simcoe cannula. AC formed with BSS through the side port.

Intracameral moxifloxacin 500 micrograms in 0.1 ml injected through the side port.

Closure

Tunnel tested: self-sealing, no leak. No sutures.

Conjunctiva apposed over the tunnel with cautery. Bridle suture removed.

Pressure patch applied.

Implant

IOL: rigid PMMA single piece, 6.0 mm optic, 12.5 mm overall, power 21.5 D, A-constant 118.0. Lot no. ________, serial no. ________, expiry ________. Sticker pasted here. Barcode number copied to the claim form and discharge summary.

End of procedure

Posterior capsule intact. No vitreous loss. No intra-operative complications.

Instrument and needle count correct, confirmed by scrub nurse.

Patient walked to the ward with an attendant. Pulse 78/min, BP 140/82 mmHg.

Post-op orders

Keep the pad on till review tomorrow morning. Do not rub or press the eye.

From POD 1: steroid eye drops as per unit regimen, tapered over 6 weeks; antibiotic eye drops 4 times a day for 1 week.

Night shield for 10 days. No bending or lifting weights.

Review POD 1 for vision, wound, AC reaction, IOL position and IOP. Come back at once if pain or vision drops.

Follow-up at 1 week and 4 to 6 weeks for refraction.

Signature

Dr A., JR-2, Ophthalmology. Reg. no. ________. 09/02/2026, 10:55.

Must document for this operation

  • Eye operated, written in full, and that it was marked and checked at time out. Wrong-eye surgery cannot be defended, and the note is the proof that the check was done.
  • IOL make, model, power, A-constant, lot and serial number, with the sticker. Needed for a lens recall, for a wrong-power complaint, for the next surgeon doing an exchange, and for scheme claims.
  • Biometry values and that the IOL power was checked against them before the lens was opened. A refractive surprise is judged on whether the chosen power matched the measurements.
  • Anaesthesia block type, drug, strength and volume, and who gave it. Block complications such as globe perforation or retrobulbar haemorrhage are traced back to this entry.
  • Capsulotomy type and posterior capsule status at the end. A can-opener capsulotomy or a rent changes where the IOL sits and how the eye is followed up for retinal problems.
  • Any intracameral or subconjunctival drug with dose and volume. If toxic anterior segment syndrome or an allergic reaction occurs, the exact drug and dilution must be known.
  • Whether the wound was sutured and how many sutures. The OPD doctor needs to know if sutures are there to remove, and a sutured wound explains early astigmatism.

Common mistakes in these notes

  • Writing 'SICS with PCIOL done' with no eye, no IOL power and no sticker.
  • Not recording whether the capsule was intact, or writing 'uneventful' after a small rent.
  • Leaving out the block drug and volume because the anaesthetist or nurse gave it.
  • Copying the biometry power into the note without checking it against the lens actually used.
  • Not writing the capsulotomy type, so the next surgeon does not know why the IOL is in the sulcus.

Indian practice and paperwork

  • Under AB PM-JAY (HBP 2022), SICS with a non-foldable IOL is procedure code SE020B, and phaco with a foldable IOL is SE020A. The note must describe the technique and IOL actually used so that it matches the booked code. (NHA HBP 2022 package master (SACHIS HBP-2022, Ladakh HBP 2022 mapping))
  • For PM-JAY claims after cataract surgery with an IOL, the barcode number on the lens must be mentioned or attached with the claim. (NHA National Health Benefit Package 2.2 User Guidelines, https://hem.nha.gov.in/HBP.pdf)
  • NABH requires the batch and serial number of an implant to be recorded in the medical record, the master logbook and the discharge summary. An IOL is an implant. (NABH 5th ed., MOM.10(d))
  • The NHSRC patient safety tool checks that biometry results are re-verified before IOL implantation. (SaQushal Patient Safety Self-Assessment Tool, NHSRC/MoHFW 2022)
  • MSICS is the cataract operation most Indian residents learn first: in a survey of 740 residents, 97.1% of those operating independently had MSICS exposure and 14.1% phaco. (Nair AG et al., Indian J Ophthalmol 2023;71(3):743-749, PMID 36872669)

Sources

  • Steinert RF, ed. Steinert's Cataract Surgery. 4th ed. Elsevier; 2023, Ch 21, Extracapsular Cataract Extraction and Manual Small-Incision Cataract Surgery (MSICS section), pp. 191-196.
  • Steinert RF, ed. Steinert's Cataract Surgery. 4th ed. Elsevier; 2023, Ch 12, Anesthesia for Cataract Surgery; Ch 14, Antibiotic Prophylaxis and Endophthalmitis; Ch 45, Risk Management in Cataract Surgery, pp. 109-114; 120-122; 419.
  • Clinical Atlas of Procedures in Ophthalmic and Oculofacial Surgery, Ch 1, Anesthesia for Cataract Surgery; Ch 2, Incisions for Cataract Surgery; Ch 7, Manual Small Incision Cataract Surgery (Venkatesh R, Tabin G, Feilmeier M), pp. 3-8; 9-13; 48-58.

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.

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