Trabeculectomy with MMC

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

• pressure too low after surgery (hypotony), shallow or flat anterior chamber
• choroidal effusion or haemorrhage, including suprachoroidal haemorrhage
• bleb leak or wound leak
• bleb failure from scarring, needing needling, more drops or further surgery
• bleb infection (blebitis) and endophthalmitis, even years later
• cataract formation or progression
• bleeding into the anterior chamber (hyphaema)
• loss of vision in advanced glaucoma
• uncomfortable or overhanging bleb, drooping lid

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 glaucoma and indicatione.g. POAG / PACG / secondary; failed or not tolerated medical or laser treatment; progression on fields
3. Baseline measurementsbest-corrected vision, IOP with number of drops, cup-disc ratio, latest field (MD), gonioscopy
4. Conjunctiva at the planned sitemobile / scarred; previous surgery
5. Glaucoma drops and systemic acetazolamidewhat was stopped or continued before surgery
6. Anticoagulants / antiplateletsstatus on the day

Anaesthesia and position

1. AnaesthesiaPeribulbar blockSub-Tenon blockTopicaldrug, strength, volume, time, who gave it
2. Preparationantiseptic, strength and contact time; lashes isolated
3. TractionCorneal traction suturesuture material; eye rotated down to expose the upper quadrant

Operative findings

1. Conjunctiva and Tenon'sthin / thick / scarred; buttonhole made or not
2. Scleral thicknessnormal / thin
3. Anterior chamber and irisdepth; iris came through the sclerostomy easily; ciliary processes seen or not
4. Flow after flap closureSlow controlled flow, chamber maintainedExcess flow, extra sutures placedNo flow, sutures loosened

Procedure (steps)

1. Quadrant and meridians markedsite (e.g. superior, 12 o'clock); marking pen
2. Conjunctival flapFornix-based (limbal peritomy)Limbus-based (incision about 10 mm behind limbus)width; Tenon's separated from sclera; any buttonhole and how repaired
3. Haemostasislight cautery to episcleral vessels
4. Mitomycin Cconcentration (mg/ml), how applied (soaked sponges: number and size), where (on uncut sclera / under the scleral flap), time in minutes, kept away from conjunctival edge and cornea, sponges counted out, irrigation volume
5. Scleral flapRectangularTriangularsize in mm, about half thickness, hinged at the limbus, dissected forward into clear cornea
6. Paracentesisposition in clock hours
7. Sclerostomyentered with a sharp blade; widened with Kelly Descemet punch (number of bites); stopped about 1 mm short of the flap sides
8. Peripheral iridectomyDone, broad-basedNot done (reason)patent; ciliary processes and vitreous not disturbed
9. Scleral flap suturesnumber, material (e.g. 10-0 nylon), fixed / releasable, position; titrated to flow
10. Flow checkAC refilled with BSS through the paracentesis; flow at flap edges; chamber depth

Closure, drains and dressing

1. Conjunctiva and Tenon'sFornix-based: secured to cornea at both ends (wing sutures) with or without mattress suturesLimbus-based: running closure, Tenon's and conjunctiva in one or two layerssuture material and size
2. Bleb formed and leak testBSS through the paracentesis; bleb height and extent; Seidel test result
3. Traction suture removed
4. Subconjunctival / topical drugs at endonly if given: drug, dose, site (away from the bleb)
5. Pad and shield

Specimens and implants

1. SpecimenNoneIris / trabecular tissue sent for HPE (reason)
2. Mitomycin Cstrength, batch number, prepared by whom, time made up

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. Pad and shieldtill first-day review; shield at night; do not rub or press the eye
2. First post-op reviewnext morning: vision, IOP, AC depth, bleb height and extent, Seidel test, hyphaema, choroidal effusion
3. Steroid eye dropsdrug, frequency and taper as per unit regimen
4. Antibiotic eye dropsdrug and frequency
5. Glaucoma drops in the operated eyewrite which drops stop or continue in each eye, as decided by the consultant
6. Low IOP / shallow chamberIOP below about 6 mmHg on two visits or a shallow chamber: inform consultant; cycloplegic, steroid taper, viscoelastic reformation as decided
7. Suture managementplan for laser suture lysis or removal of releasable sutures if IOP rises
8. Activityavoid rubbing, bending and heavy lifting at first
9. Warning signspain, redness, discharge or drop in vision, now or years later: come the same day (bleb infection)

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