OT notes · Ophthalmology

Trabeculotomy / goniotomy (congenital glaucoma)

Usual anaesthesia
General
Position
Supine, head turned as needed for the angle view (goniotomy) or straight (trabeculotomy), operating microscope
Setting
elective

Operative note template for angle surgery in childhood glaucoma (goniotomy or trabeculotomy ab externo), with a filled example for trabeculotomy ab externo with a metal trabeculotome in an infant with primary congenital glaucoma and a hazy cornea.

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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

  • bleeding into the front of the eye (hyphaema), common after trabeculotomy
  • pressure not controlled; repeat angle surgery or other glaucoma surgery may be needed
  • injury to the lens and later cataract
  • tear or stripping of Descemet's membrane, corneal scar
  • wrong passage of the probe (false passage) or conversion to trabeculectomy
  • wound leak, shallow anterior chamber
  • infection inside the eye (rare)
  • need for repeated examinations under anaesthesia (EUA)
  • glasses and amblyopia treatment will still be needed

Pre-operative details for this operation

  1. DiagnosisPrimary congenital glaucomaOther primary childhood glaucomaAniridia with progressive angle closure
  2. EyeRightLeftBoth (state order)
  3. EUA findingsIOP (tonometer, anaesthetic depth), horizontal corneal diameter (mm), corneal clarity, Haab striae, gonioscopy, cup-disc ratio, axial length
  4. Choice of procedureGoniotomy (clear cornea, angle visible)Trabeculotomy ab externo (cornea hazy)Combined trabeculotomy-trabeculectomy
  5. Pupilpilocarpine 2% (and apraclonidine 0.5% for goniotomy) instilled before surgery
  6. Eye markedYes

Anaesthesia and position

  1. AnaesthesiaGeneral
  2. IOP measured after inductionvalue, tonometer, time after induction
  3. PositionHead turned 45 degrees away from surgeon, microscope tilted (goniotomy)Supine, head straight (trabeculotomy)

Operative findings

  1. Corneaclear / hazy / epithelial oedema scraped for view
  2. Anglefor goniotomy: appearance of the angle, white cleft seen as the incision proceeds
  3. Schlemm's canalFound, probe passed easilyFound with difficultyNot foundegress of fluid or blood on entry
  4. Extent of angle openedclock hours or degrees
  5. Hyphaema at endNoneMildSignificant

Procedure (steps)

  1. ProcedureGoniotomyTrabeculotomy with metal trabeculotome360-degree suture trabeculotomyCombined trabeculotomy-trabeculectomy
  2. Goniotomy: eye fixed and lens placedlocking forceps at 12 and 6 o'clock; Barkan or other goniolens
  3. Goniotomy: entry and incisionneedle or knife (gauge / type), entry site opposite the angle to be cut, viscoelastic, clock hours cut
  4. Trabeculotomy: conjunctival incisionLimbal (fornix based)Limbus basedquadrant
  5. Trabeculotomy: scleral flapshape, size (mm), depth, blades used
  6. Trabeculotomy: radial scratch incision to Schlemm's canalegress of fluid; canal confirmed with blunted polypropylene 6-0 suture
  7. Paracentesis and viscoelastic in AC
  8. Trabeculotome passed and rotatedeach direction, clock hours opened; or suture passed 360 degrees and pulled
  9. AC reformedBSS / viscoelastic; air bubble left or not

Closure, drains and dressing

  1. Scleral flapnumber of sutures and material, e.g. interrupted polyglactin 10-0; watertight
  2. Conjunctivamaterial and number of sutures
  3. Corneal entry (goniotomy)single polyglactin 10-0 suture or none
  4. Subconjunctival injectionantibiotic and short-acting steroid: drugs and doses
  5. ShieldShieldPad and shield

Specimens and implants

  1. SpecimensNone

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. Feedingbreast or formula feed when awake, as advised by anaesthetist
  2. Head positionafter goniotomy: lie on the operated side so blood settles away from the cleft
  3. Topical dropsantibiotic, steroid and miotic: drugs, frequency, duration
  4. Day 1 checkAC formed (air bubble), hyphaema, wound, cornea
  5. Analgesiadrug and dose by weight
  6. EUAdate of next examination under anaesthesia to check IOP, corneal diameter and disc
  7. Other eyeplan for the fellow eye if also affected
  8. Refraction and amblyopia careplan once the cornea clears

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: Baby N.P., male, 4 months, 6.5 kg, bilateral primary congenital glaucoma, worse in the right eye. Right cornea hazy with Haab striae, so angle view not possible for goniotomy.

Case details

Date: 26/06/2026. Elective (semi-urgent). Eye OT 1.

In OT 08:40. GA induced 08:45. EUA 08:50. Incision 09:05. End 10:05.

Surgeon: Dr C. (consultant, glaucoma). Assistant: Dr A. (3rd-year resident). Anaesthetist: Dr D. (paediatric anaesthesia). Scrub nurse: Sr E.

Indication and pre-op

Watering, photophobia and enlarging eyes since 2 months of age.

EUA today under sevoflurane, 3 minutes after induction: IOP by rebound tonometer right 32 mmHg, left 24 mmHg. Horizontal corneal diameter right 13.0 mm, left 12.0 mm. Right cornea hazy with Haab striae; left cornea clear. Right disc view poor; left cup-disc 0.5.

Plan: right trabeculotomy ab externo, because the hazy cornea prevents a clear view for goniotomy. Left eye: IOP and corneal diameter also raised; angle surgery on the left to be planned at the next EUA.

Consent: general, procedure-specific and anaesthesia consent from both parents in Kannada, including hyphaema, repeat surgery and repeated EUAs.

Right eye marked. WHO checklist sign in and time out done. Pilocarpine 2% instilled pre-op.

Anaesthesia and position

General anaesthesia with endotracheal tube. Supine, head straight. Periocular skin painted with povidone-iodine and draped. Infant speculum.

Procedure

Limbal conjunctival incision at 12 o'clock with Westcott scissors, about 5 mm wide.

Triangular partial-thickness scleral flap about 4 mm wide, base at the limbus, made with a 15-degree super-sharp blade and Beaver 64 blade.

Radial scratch incision under the flap with the super-sharp blade, deepened layer by layer. Schlemm's canal entered with a small egress of blood-tinged fluid.

Canal confirmed with a polypropylene (Prolene) 6-0 suture blunted at the tip with cautery: passed easily in both directions.

Paracentesis at 2 o'clock. Viscoelastic injected into the AC.

Curved metal trabeculotome passed into the right cut end of the canal until resistance, then rotated into the AC, watching the outer arm. Withdrawn. Same done in the left cut end. About 4 clock hours of angle opened. AC topped up with viscoelastic between passes.

Mild hyphaema from the angle. AC partly washed with BSS, some viscoelastic left in.

Closure

Scleral flap closed with 3 interrupted polyglactin 910 (Vicryl) 10-0 sutures, watertight. Conjunctiva closed with 2 interrupted Vicryl 10-0 sutures at the limbus.

Small filtered air bubble left in the AC. Subconjunctival antibiotic and short-acting steroid injected (as charted). Shield applied.

End of procedure

Blood loss negligible. Complication: mild hyphaema, expected. No Descemet's tear. Lens not touched.

Needle and instrument count correct.

Specimens: none.

Shifted to recovery, extubated, crying, SpO2 99%. Handed to paediatric recovery nurse.

Post-op orders

Breastfeed when fully awake, as per anaesthetist.

Syrup paracetamol by weight as charted.

Shield on. Topical antibiotic, steroid and pilocarpine drops to the right eye as written on the drug chart.

Day 1: check AC depth (air bubble), hyphaema and wound.

EUA to be booked to check IOP and corneal diameter both eyes, and to plan the left eye.

Signature

Dr A., JR-3, Ophthalmology, for Dr C. Reg. no. ________. 26/06/2026, 10:15.

Must document for this operation

  • EUA values with the time after induction and the tonometer used. IOP under anaesthesia changes with the agent and time, so later EUAs can only be compared if these are written.
  • Horizontal corneal diameter of both eyes. It is the main sign of progression in infants and is followed at every EUA.
  • Procedure done and why (goniotomy needs a clear cornea). Explains the choice to the next surgeon and is needed if the operation is repeated in another part of the angle.
  • Quadrant operated and clock hours of angle opened. A repeat angle operation is done in the untreated part of the angle.
  • Whether Schlemm's canal was found easily or a false passage was suspected. A poor result after a difficult cannulation points to a false passage rather than failure of the angle.
  • Hyphaema and any Descemet's tear or lens touch. These complications change post-op checks and explain later corneal scars or cataract.

Common mistakes in these notes

  • Not writing the corneal diameter and IOP at the EUA.
  • Writing 'trabeculotomy done' with no clock hours or quadrant.
  • Not recording the fellow eye findings and plan.
  • Recording IOP without the anaesthetic agent and time after induction.
  • Leaving out the air bubble or viscoelastic left in the AC, which the day-1 examiner needs to know.

Indian practice and paperwork

  • Consent must explain risks, benefits and alternatives in a language the parents understand, and is taken by the operating surgeon. Record which parent consented. (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, including the next EUA date. (NABH 5th ed., COP.14(e) and (f))

Sources

  • Albert DM, Lucarelli MJ, eds. Clinical Atlas of Procedures in Ophthalmic and Oculofacial Surgery. 2nd ed. Oxford University Press; 2012, Ch 64, Pediatric Glaucoma Surgery (Yanovitch TL, Freedman SF), pp. 620-629.
  • Roper-Hall MJ. Stallard's Eye Surgery. 7th ed. Wright (Butterworths); 1989, Ch 9, Glaucoma: goniotomy for infantile glaucoma; trabeculotomy ab externo, pp. 335-341.
  • Khan AO, chair. Basic and Clinical Science Course, Section 6: Pediatric Ophthalmology and Strabismus. 2024-2025 ed. American Academy of Ophthalmology; 2024, Ch 21, Childhood Glaucoma (diagnostic criteria; effect of anaesthesia on IOP; surgical decisions), pp. 297-303.

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

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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