Incision and drainage of orbital abscess (anterior orbitotomy)

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 behind the eye (retrobulbar haemorrhage) and loss of vision
• damage to the optic nerve with loss of vision
• injury to the eyeball, retina or eye muscles; double vision
• damage to nerves: numbness of cheek or forehead, droopy lid
• persistent or recurrent abscess needing a second drainage
• change in lid position or lateral canthus shape
• need for sinus surgery by the ENT team at the same sitting
• spread of infection to the brain (meningitis, abscess) despite surgery

Pre-operative details for this operation

1. SideRightLeft
2. Source of infectionEthmoid sinusitisFrontal sinusitisMaxillary sinusitisDentalTrauma / foreign bodyOther
3. ImagingCT orbit and sinuses, axial and coronal, with contrast: site of abscess (medial, inferior, superior, intraconal), size, sinuses involved, intracranial extension
4. Visual acuity, pupils, colour visionaffected and fellow eye; RAPD present or absent
5. Proptosis, ocular movements, IOP
6. Reason for surgeryabscess on CT, no improvement or worse on IV antibiotics (duration), falling vision, intracranial signs
7. IV antibiotics so fardrugs, start date and time
8. ENT / neurosurgery opinioncombined endoscopic sinus surgery planned or not
9. Side markedYes

Anaesthesia and position

1. AnaesthesiaGeneral
2. Local infiltration for haemostasisdrug, concentration, adrenaline strength, volume
3. PositionSupine, head raised
4. Corneal protector / globe protectionCorneal protectorMalleable retractor only

Operative findings

1. Site of abscessSubperiosteal, medial wallSubperiosteal, floorSubperiosteal, roofIntraorbital / intraconal
2. Pusamount (ml), colour, smell; under pressure or not
3. Periosteum and boneperiosteum lifted, bone dehiscence of lamina papyracea or floor
4. Orbital fat and musclesinflamed, necrotic, normal
5. Globe tension at endSoftFirm

Procedure (steps)

1. ApproachTransconjunctival inferior orbitotomyTranscaruncular medial orbitotomyUpper eyelid crease (superior) orbitotomyEndoscopic transnasal (ENT)chosen from the CT site of the abscess
2. Traction suturesmaterial and position, e.g. silk 4-0 through lid margin or conjunctiva and retractors
3. Lateral canthotomy and inferior cantholysisDoneNot neededblade and cautery used
4. Incisiontransconjunctival (below the tarsus), transcaruncular (plane between medial 3/4 and lateral 1/4 of caruncle) or lid crease; blade or cutting cautery
5. Dissection to the orbital rimglobe protected with malleable retractor; plane of dissection
6. Periosteum incised and subperiosteal plane enteredrim and wall along which dissection was done
7. Pus drainedamount; swab and pus sent for culture
8. Cavity irrigatedsolutions used in order (e.g. hydrogen peroxide, povidone-iodine, normal saline)
9. DrainPenrose through separate lid stabPenrose through incisionNo drainwhere the tip lies, how secured
10. Sinus surgeryNot doneEndoscopic sinus surgery by ENT, same anaesthesia (separate note)

Closure, drains and dressing

1. Conjunctiva / caruncleClosed with absorbable sutureLeft openmaterial and size, e.g. chromic 6-0
2. Lateral canthustarsus reattached to lateral orbital tubercle: material and size, e.g. polyglactin 4-0
3. Skin (if lid crease incision)orbicularis and skin layers, material and size
4. Orbital septumNot closed
5. DressingLight pad, eye checkableNo padavoid a tight pressure dressing that stops vision checks

Specimens and implants

1. Pus / swab for cultureaerobic, anaerobic, fungal as requested; Gram stain
2. Tissue for HPENot sentSent (reason, e.g. suspected fungal infection)
3. Draintype and size, number

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. Vision checksvisual acuity, pupils (RAPD), proptosis and pain at a written interval; call the resident at once if vision drops or the eye becomes tense
2. IV antibioticscontinue; drugs, doses; review with culture report
3. Drainrecord output; plan removal at 24 to 48 hours
4. Head endraised
5. Nasal careas advised by ENT if sinus surgery was done
6. Analgesiadrug, dose, frequency
7. Temperature and inflammatory markersfever chart; repeat blood counts as ordered
8. Repeat imagingif no improvement or vision worsens

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