OT notes · Ophthalmology

Phacoemulsification with foldable IOL

Usual anaesthesia
Topical (drops or gel), often with intracameral preservative-free lignocaine; peribulbar or sub-Tenon block for dense cataracts or anxious patients
Position
Supine, head stable on a head ring, operating microscope
Setting
elective

Operative note template for phacoemulsification with a foldable posterior chamber IOL, with a filled example for a grade 3 nuclear cataract done under topical anaesthesia through a temporal clear corneal incision.

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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
  • conversion to manual small incision or large incision surgery
  • IOL placed in the sulcus or not placed at the same sitting
  • infection inside the eye (endophthalmitis)
  • corneal swelling, corneal wound burn
  • raised eye pressure after surgery
  • wound leak needing a suture
  • discomfort during surgery under topical anaesthesia
  • need for glasses for near or distance after surgery

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. Cataract grade and pupilnuclear grade, dilated pupil in mm, pseudoexfoliation, phacodonesis, red reflex
  3. Visual acuity, IOP, fundusbest-corrected vision, IOP in mmHg, fundus / B-scan
  4. Biometry and IOL choiceaxial length, K1/K2, formula, target refraction, IOL model and power; re-checked against the lens in OT
  5. Specular count / corneaendothelial count if done, guttae
  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. AnaesthesiaTopical dropsTopical with intracameral preservative-free lignocaine 1%Peribulbar blockSub-Tenon blockGeneraldrug, strength, volume, time, who gave it
  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. Speculumtype

Operative findings

  1. Nucleus densitySoftMediumHard / brunescent
  2. Anterior chamber and pupil during surgerystable / shallow; pupil maintained / constricted; iris prolapse
  3. Zonulesintact / weak / 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. Side port (paracentesis)position in clock hours
  2. Viscoelastic (OVD)DispersiveCohesiveBoth (soft shell)
  3. Main incisionTemporal clear cornealSuperior clear cornealScleral tunnelwidth in mm, blade used, single plane / grooved
  4. Capsule stainTrypan blueNot used
  5. Capsulorhexiscontinuous curvilinear, instrument (cystotome / forceps), size in mm (about 5.0 to 5.2 mm to overlap a 6 mm optic); any radial tear
  6. Hydrodissection / hydrodelineationcannula; nucleus rotated freely
  7. Nucleus managementDivide and conquerStop and chopHorizontal phaco chopVertical phaco chopPrechopProlapse and phaco in the anterior chambersecond instrument used
  8. Cortex removalCoaxial I/ABimanual (biaxial) I/Asubincisional cortex cleared; capsule polished if done
  9. IOL implantationFoldable IOL in the bag with injector3-piece foldable IOL in the sulcusbag filled with OVD first; model, material, power, A-constant; centred
  10. OVD removalincluding from behind the IOL
  11. Intracameral antibioticMoxifloxacinCefuroximeNot givendrug, dose, 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. Wound sealingStromal hydration, self-sealingSelf-sealing without hydrationSingle radial 10-0 nylon sutureSeidel test / checked for leak
  2. Eye pressure at enddigitally normal / firm
  3. Pad / shieldShield onlyPad and shieldPressure patch (after block)

Specimens and implants

  1. IOL detailsmake, model, material (hydrophobic / hydrophilic acrylic), single-piece or 3-piece, 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. Capsular tension ring or other deviceNot usedUsed (size, lot)

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. Shieldshield on till first-day check; do not rub or press the eye
  2. First post-op reviewnext morning: vision, wound (Seidel if doubtful), corneal clarity, AC cells, IOL position, IOP
  3. Steroid eye dropsdrug, frequency and taper as per unit regimen
  4. Antibiotic eye dropsdrug; commonly 4 times a day for 5 to 7 days
  5. Suture removalif a 10-0 nylon suture was placed: remove at the slit lamp at 1 to 2 weeks
  6. Warning signspain, drop in vision, redness, discharge: come back the same day
  7. Follow-up and glassesreview dates; refraction after the drops are finished

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: Mr. R.K., 61 years, nuclear cataract grade 3 in the left eye, best-corrected vision 6/36, IOP 14 mmHg, fundus normal, pupil dilates to 7.5 mm.

Case details

Date: 17/03/2026. Elective. Eye OT 2.

Incision 11:20. IOL in 11:34. Shield applied 11:40.

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

Scrub nurse: Sr E.

Indication and pre-op

Left eye (LE) nuclear cataract grade 3, glare and reading difficulty. No pseudoexfoliation, no phacodonesis.

Biometry (optical): axial length 23.62 mm, K1 43.75 D, K2 44.50 D, Barrett formula, target -0.25 D. IOL: single-piece hydrophobic acrylic, 6.0 mm optic, 21.0 D.

Consent: general and procedure-specific consent in English, including capsule rupture, dropped nucleus, endophthalmitis, conversion and need for reading glasses. LE marked above the left eyebrow. No cephalosporin allergy.

WHO checklist sign in and time out done. Eye, IOL model and power read aloud and checked against the biometry sheet before the lens was opened.

Anaesthesia and position

Topical anaesthesia: proparacaine 2 drops before preparation. Preservative-free lignocaine 1%, 0.3 ml intracameral through the side port.

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

Procedure

Side port at 12 o'clock with a side port blade. Anterior chamber filled with dispersive OVD.

Temporal clear corneal incision, 2.2 mm, single plane with a keratome.

Continuous curvilinear capsulorhexis of about 5.2 mm with a cystotome and forceps, no radial tear.

Hydrodissection with BSS through a 27 G cannula; nucleus rotated freely.

Nucleus managed by stop and chop: one central groove, nucleus cracked into halves, each half chopped with a chopper through the side port and emulsified.

Cortex removed with coaxial I/A, subincisional cortex cleared. Posterior capsule intact.

Capsular bag filled with cohesive OVD. Foldable single-piece hydrophobic acrylic IOL, 21.0 D, injected into the bag through the main incision with an injector and cartridge. Centred well.

OVD removed with I/A, including from behind the optic.

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

Closure

Stromal hydration of the main incision and side port with BSS. Wound tested with fluorescein: Seidel negative. No suture.

Eye digitally normotensive. Speculum removed. Shield applied.

Implant

IOL: single-piece hydrophobic acrylic, 6.0 mm optic, 13.0 mm overall, power 21.0 D, A-constant ______ (from lens box). 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. Pulse 76/min, BP 132/80 mmHg.

Post-op orders

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

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

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

Follow-up at 1 week and 4 weeks, refraction at the last visit.

Signature

Dr A., JR-3, Ophthalmology. Reg. no. ________. 17/03/2026, 11:55.

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, material, power, A-constant, lot and serial number, with the sticker. Needed for a lens recall, for a refractive surprise, for an IOL exchange later, and for scheme claims.
  • That the IOL was checked against the biometry sheet before opening. Wrong IOL placement is one of the most common medicolegal problems after cataract surgery.
  • Capsulorhexis size and posterior capsule status at the end. A rent changes where the IOL sits and means the retina must be watched more closely.
  • Nucleus technique and any conversion. If the cornea swells or the capsule tears, the note shows what was done and why the plan changed.
  • Intracameral drugs with dose and volume. If toxic anterior segment syndrome or an allergic reaction occurs, the exact drug and dilution must be known.
  • Whether a suture was placed. The OPD doctor needs to know to remove it at 1 to 2 weeks.

Common mistakes in these notes

  • Writing 'phaco with PCIOL done' with no eye, no IOL power and no sticker.
  • Writing 'uneventful' when there was a small capsule tear or zonular dialysis.
  • Leaving out intracameral drugs because the nurse loaded them.
  • Not writing incision site and width, so the next surgeon cannot plan astigmatism or a glaucoma operation.
  • Recording the planned IOL instead of the one actually implanted.

Indian practice and paperwork

  • Under AB PM-JAY (HBP 2022), phaco with a foldable hydrophobic acrylic IOL is procedure code SE020A, and SICS with a non-foldable IOL is SE020B. 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. (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)

Sources

  • Steinert RF, ed. Steinert's Cataract Surgery. 4th ed. Elsevier; 2023, Ch 16 Incision Construction; Ch 17 Capsulotomy; Ch 18 Hydrodissection and Hydrodelineation; Ch 22 Principles of Nuclear Disassembly; Ch 27 Cortical Removal, pp. 133-138; 143-156; 157; 197-203; 235-236.
  • 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; Ch 3 Anterior Capsulotomy Techniques; Ch 4 (IOL injection, Fig 4.13); Ch 5 Phaco Prechop, pp. 3-8; 9-13; 14-17; 24; 27-42.

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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