Strabismus surgery (recession / resection of horizontal recti)

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

• undercorrection or overcorrection, with possible second operation
• double vision after surgery
• scleral perforation by the needle, rarely retinal detachment or endophthalmitis
• lost or slipped muscle needing re-exploration
• infection: conjunctivitis, orbital cellulitis
• anterior segment ischaemia when several recti are operated
• conjunctival scarring, cyst or granuloma at the incision
• change in eyelid position after vertical rectus surgery
• slowing of heart rate on muscle traction (oculocardiac reflex)
• glasses and patching may still be needed after surgery

Pre-operative details for this operation

1. Type of deviationEsotropiaExotropiaIntermittent exotropiaConsecutive / residualconstant or intermittent, eye that deviates
2. Angle of deviation (prism dioptres)distance and near, primary position; method: prism cover test / Hirschberg / Krimsky
3. Comitance and patternsside-gaze and distance-near difference, A or V pattern, restriction
4. Visual acuity and refractioneach eye, with glasses; amblyopia present / treated
5. Binocular statusfusion, stereopsis, diplopia, suppression
6. Surgical plan written before surgeryeye, muscle, recession or resection, amount in mm, with the dosage table used
7. Previous eye surgeryprevious strabismus surgery (which muscles), trabeculectomy or tube, retinal buckle
8. Eye markedRightLeftBoth

Anaesthesia and position

1. AnaesthesiaGeneralPeribulbarRetrobulbarTopicalGeneral with sub-Tenon block
2. Muscle relaxant notedsuccinylcholine affects the forced duction test for a while; note if used
3. PositionSupine, head straight

Operative findings

1. Forced duction testFree in all directionsRestricteddirection and eye if restricted
2. Muscle insertiondistance of insertion from limbus in mm, tendon width, any split or anomalous insertion
3. Muscle qualityNormalThin / fibroticScarred from previous surgery
4. Inferior oblique or superior oblique seen on the hookNot includedIncluded and separated
5. Oculocardiac reflexNot seenBradycardia on tractionheart rate, action taken

Procedure (steps)

1. Speculum and forced duction test
2. Conjunctival incisionLimbal (peritomy) with radial relaxing cutsFornixLimbal, 1-2 mm behind limbusquadrant
3. Muscle hookedStevens hook then Jameson hook; check the hook tip is bare and the full width is on the hook
4. Tenon's capsule, check ligaments and intermuscular septum clearedhow far back (mm); posterior Tenon's kept intact
5. Suture placed in the tendon / musclematerial, size, needle, locking bites at each edge; within 1 mm of insertion for recession, at the measured point for resection
6. RecessionDirect scleral reattachmentHang-backAdjustable (sliding noose)amount in mm, measured from the original insertion with calipers; scleral pass crossed-swords or parallel
7. ResectionClamp (Jameson)Sutures before clampPlicationamount in mm from insertion; muscle anterior to sutures excised; stump cauterised; reattached to original insertion stump
8. Knots tied and muscle checked securesuture intact, muscle at planned position
9. Vertical shift of insertion (if A/V pattern)Not doneUp half tendon widthDown half tendon widthUp one tendon widthDown one tendon width
10. Second muscle / other eyerepeat the same details for each muscle operated
11. Needle passes checkedany suspected scleral perforation; fundus examined with indirect ophthalmoscope if suspected

Closure, drains and dressing

1. ConjunctivaInterrupted corner suturesRecessed conjunctiva (bare sclera left)Fornix incision left self-sealingmaterial and size, e.g. polyglactin 8-0
2. Plica semilunarisfor medial rectus via limbal incision: plica identified and not sutured into the closure
3. Topical medication at endantibiotic drop / ointment used
4. PadPad and shieldNo pad

Specimens and implants

1. Resected muscle segmentDiscarded as human anatomical wasteSent for HPE (reason)Not applicable (recession only)
2. Adjustable suture left for adjustmentNoYes: time of planned adjustment

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. Monitoringpulse, SpO2 till fully awake; watch for nausea and vomiting
2. Nausea and vomitingeye muscle surgery carries a high risk; antiemetic as charted by the anaesthetist
3. Oral intakesips when awake, then normal diet
4. Analgesiadrug and dose by body weight
5. Eye dropstopical antibiotic (drug, frequency, duration)
6. Warning signs to explainlid swelling, proptosis, fever, pain or drop in vision in the first 2-3 days: come back at once (orbital cellulitis, endophthalmitis)
7. Adjustable sutureif used: time of adjustment, not before half a day after a local block
8. Glasses and patchingcontinue the pre-op spectacles and amblyopia treatment as advised
9. Follow-upnext day, then as per unit schedule with orthoptic measurement of the new angle

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