OT notes · Ophthalmology

Tarsorrhaphy

Usual anaesthesia
Local: topical anaesthetic drops plus infiltration of lignocaine 2% with adrenaline into the lid margins
Position
Supine
Setting
elective

Operative note template for temporary or permanent tarsorrhaphy, with a filled example for a paramedian tarsorrhaphy done to protect the cornea in a facial nerve palsy expected to recover.

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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

  • narrowed eye opening and restricted view until the lids are opened
  • adhesion giving way early
  • lash damage and later in-turning lashes (trichiasis)
  • notching or scarring of the lid margin
  • bleeding and lid swelling
  • infection
  • suture or bolster rubbing on the cornea
  • need for a second procedure to open the lids

Pre-operative details for this operation

  1. IndicationExposure keratopathy (seventh nerve palsy, expected to recover)Neurotrophic keratitisNon-healing corneal ulcer / epithelial defectProptosis with exposureProtect lid skin graftPermanent seventh nerve palsy (no recovery expected)state duration and what has been tried (lubricants, ointment, taping, bandage lens)
  2. Eye and sideRightLeft
  3. Corneal statusepithelial defect size in mm, stain, sensation, infiltrate
  4. Lagophthalmosgap in mm on gentle closure; Bell's phenomenon
  5. Visual acuity of both eyesmatters because the operated eye will see less
  6. Planned typeTemporary (suture only)Temporary paramedian with raw lid-margin areasLateral / permanent

Anaesthesia and position

  1. AnaesthesiaLocal: topical drops + lid infiltrationGeneral (child, or combined with another operation)drug, strength, adrenaline
  2. PositionSupine

Operative findings

  1. Lid marginshealthy, inflamed, scarred; lashes normal
  2. Cornea at startdefect size, infiltrate
  3. Lid margins meet without tensionYesNo (proptosis): extra step needed

Procedure (steps)

  1. Painting and drapingantiseptic used
  2. Site markedParamedian: 3 mm on either side of the midline, upper and lower lids opposite each otherLateral: from the lateral canthusSuture only: points medial and lateral to the cornealength of each site in mm; number of sites
  3. Lid margin everted and heldtwo hooks or traction; lower lid done first
  4. Grey-line incisiondepth (about 2 mm) and length (about 5 mm) at each site; blade used
  5. Marginal epithelium excisedposterior half of the lid margin removed as a strip; lash line and sharp posterior border kept intact
  6. HaemostasisPressureBipolar cautery
  7. Raw areas apposednumber of vertical mattress sutures, suture material and size, bolster (rubber tube, IV cannula tubing, silicone)
  8. Suture-only temporary tarsorrhaphyhorizontal mattress through skin and tarsal plate, not full thickness; exit close to the lashes; tied loosely over tubing
  9. Sutures tiedraw areas cleared of clot first; tension; knots away from the cornea

Closure, drains and dressing

  1. Cornea covered at endFullyPartly (gap in mm)
  2. Ointment and dressingdrug; dressing for how long

Specimens and implants

  1. SpecimenNone (marginal epithelium discarded)

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. Dressingpad for 24 hours, then open
  2. Topical medicationlubricant or antibiotic drops or ointment instilled through the gap between the adhesions: drug, frequency
  3. Analgesiaoral drug, dose, frequency
  4. Watch forbolster slipping, suture rubbing on the cornea, discharge, pain
  5. Suture removalday (about the 14th day for a paramedian adhesion tarsorrhaphy)
  6. Cornea reviewdate; stain through the open gap
  7. Plan for openingwhen the cause settles; division under local with blunt scissors
  8. Treatment of causefacial palsy follow-up, thyroid eye disease, neurotrophic keratitis plan

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. S.K., 52 years, left lower motor neuron facial palsy (Bell's palsy) for 6 weeks with partial recovery, 4 mm lagophthalmos, weak Bell's phenomenon and a 2 x 3 mm inferior corneal epithelial defect not healing after 2 weeks of lubricants and night ointment.

Case details

Date: 16/04/2026. Elective, minor OT. Start 10:20. End 10:55.

Surgeon: Dr A. (2nd-year resident, Ophthalmology). Assistant: Dr B. Consultant: Dr C., present.

Anaesthesia: local by surgeon. Scrub nurse: Sr D.

Indication and pre-op

Indication: left exposure keratopathy with non-healing inferior epithelial defect, 2 x 3 mm, no infiltrate. Lagophthalmos 4 mm. Facial palsy expected to recover, so temporary paramedian tarsorrhaphy planned.

Visual acuity: right 6/6, left 6/18. Patient told the left eye will see less until the lids are opened.

Consent: procedure-specific consent taken in Hindi, including restricted view, lash damage and a second procedure to open the lids.

WHO checklist done. Left eye marked.

Anaesthesia and position

Supine. Amethocaine 1% drops to the left eye. Lignocaine 2% with adrenaline 1:100000 infiltrated along the upper and lower lid margins. Painted with povidone-iodine and draped.

Procedure

Lid margins healthy. Lids met without tension.

Two sites marked with gentian violet on each lid, 3 mm on either side of the midline, upper marks exactly opposite the lower.

Lower lid done first. Lid margin everted with two hooks. Grey-line incision 2 mm deep and 5 mm long with a No. 11 blade, directed away from the lashes. Second incision in front of the sharp posterior border. Marginal epithelium between them excised, leaving a raw area 5 x 2 mm. Lash line and posterior border intact.

Same done on the upper lid at the opposite sites. Bleeding stopped with pressure.

Raw areas cleared of clot. Two double-armed 6-0 silk vertical mattress sutures at each site, one at each end of the raw area (four in all), passed through rubber bolsters on the upper and lower lid skin. Sutures tied firmly, knots on the bolsters, away from the cornea.

Closure

Two paramedian adhesions made. Small gaps left between and beside the adhesions for instilling drops. Cornea covered on gentle closure.

Antibiotic ointment instilled. Pad applied.

End of procedure

Blood loss minimal. Swab and needle count correct. No specimen: marginal epithelium discarded as yellow bag waste.

No intra-operative complications. Pulse 78/min, BP 128/80 mmHg. Sent to ward.

Post-op orders

Pad for 24 hours, then open.

Lubricant drops through the central gap as charted. Antibiotic ointment at night.

Oral paracetamol as charted if needed for pain.

Report if the bolster slips, sutures rub the eye, or pain increases.

Sutures to be removed on the 14th day.

Cornea review in the OPD on day 7. Facial palsy follow-up as planned by the physician. Division planned once eye closure recovers.

Signature

Dr A., JR-2, Ophthalmology. Reg. no. ________. 16/04/2026, 11:05.

Must document for this operation

  • The indication and what treatment was tried first. Tarsorrhaphy narrows the patient's vision, so the note must show why it was needed.
  • Type (temporary suture only, paramedian with raw areas, lateral or permanent). Opening a suture-only tarsorrhaphy is just suture removal, while an adhesion tarsorrhaphy needs division, so the next doctor must know which one it is.
  • Number, position and length of the adhesion sites. The doctor who later opens the lids needs to know exactly where the adhesions are.
  • That the lash line and the posterior lid border were kept intact. Damage to the lash roots can cause trichiasis later, and the note shows this risk was avoided.
  • Size and state of the corneal defect at surgery. This is the baseline to judge healing at review.
  • Planned suture removal day and the plan for opening. Sutures left too long or a tarsorrhaphy never reviewed are common causes of complaints.

Common mistakes in these notes

  • Writing 'tarsorrhaphy done' without the type, side and number of sites.
  • No record of what was tried before surgery (lubricants, ointment, taping).
  • Not writing the visual acuity of the other eye before closing one eye.
  • No date for suture removal or corneal review in the post-op orders.
  • Not noting whether a gap was left for instilling drops.

Indian practice and paperwork

  • Consent must explain the procedure, risks, alternatives and who will do it, in a language the patient understands, and be taken by the person doing the procedure. (NABH 5th ed., PRE.4(c) and (e))
  • 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 suture removal and review dates in that plan. (NABH 5th ed., COP.14(e) and (f))
  • Discarded tissue such as excised lid-margin epithelium is human anatomical waste and goes in the yellow bag. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Roper-Hall MJ. Stallard's Eye Surgery. 7th ed. Wright (Butterworths); 1989, Ch 3, The eyelids and reconstructive (plastic) surgery: Tarsorrhaphy, lateral canthorrhaphy, paramedian tarsorrhaphy, division of tarsorrhaphy, pp. 83-85.
  • Perry M, Holmes S, eds. Atlas of Operative Maxillofacial Trauma Surgery: Primary Repair of Facial Injuries. Springer London; 2014, Ch 18.1.1, Tarsorrhaphy (Temporary), pp. 758-765.
  • Khurana AK, Khurana AK, Khurana B. Comprehensive Ophthalmology. 6th ed. Jaypee Brothers; 2015, Ch 15, Disorders of Eyelids: lagophthalmos and tarsorrhaphy, pp. 378.
  • Roper-Hall MJ. Stallard's Eye Surgery. 7th ed. Wright (Butterworths); 1989, Ch 3, Minor surgery: local anaesthesia for lid margin lesions, pp. 134.

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

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