OT notes · Ophthalmology

Dacryocystectomy

Usual anaesthesia
Local: infratrochlear and anterior ethmoidal nerve block with infiltration along the anterior lacrimal crest, plus topical drops; general anaesthesia if needed
Position
Supine, head end raised if bleeding
Setting
elective

Operative note template for external dacryocystectomy, with a filled example for a DCT done under local anaesthesia in an elderly patient with chronic dacryocystitis who needs cataract surgery.

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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

  • watering continues after surgery (the tear drain is removed, not bypassed)
  • bleeding, including from the angular vein
  • wound infection or wound opening up
  • recurrent infection from a sac remnant
  • visible scar at the side of the nose
  • rarely, bleeding behind the eye with loss of vision, or orbital cellulitis
  • later need for a bypass operation (conjunctivo-DCR with a tube) if watering troubles the patient

Pre-operative details for this operation

  1. IndicationChronic dacryocystitis, elderly or frail patientDacryocystitis before urgent eye surgery (cataract, keratitis)Severe dry eye with dacryocystitisBleeding diathesis / anticoagulant cannot be stoppedShrunken fibrosed sacSpecific infection of sac (TB, fungal)Gross nasal disease (atrophic rhinitis)Suspected sac tumourFailed DCR with dry eyeexplain why DCR was not chosen
  2. SideRightLeft
  3. Diagnosis confirmedregurgitation on pressure over sac; syringing: regurgitation from other punctum, hard stop
  4. Canaliculipatent / blocked
  5. Schirmer test (if dry eye suspected)mm at 5 min
  6. ImagingNot neededCT / MRI (suspected tumour)
  7. Bleeding profileBT/CT, PT/aPTT, INR if on anticoagulant; drug stopped or continued
  8. Blood pressurecontrolled?
  9. Counselled that watering will continueYes

Anaesthesia and position

  1. AnaesthesiaLocal nerve block + infiltration + topicalLocal with monitored sedationGeneraldrugs, strengths, volume; adrenaline 1:200000 unless medically contraindicated
  2. PositionSupineHead end raised

Operative findings

  1. Sacsize, contents (mucus, pus), wall thickness, fibrosis, mass, diverticulum
  2. Sac intact on removalRemoved wholePerforated during dissection (remnant cleared)
  3. Periorbita / orbital septumIntactBreached (managed how)
  4. Angular veinAvoidedInjured and ligated / cauterised

Procedure (steps)

  1. Painting and drapingantiseptic
  2. Sac marked (optional)fluorescein-stained viscoelastic or methylene blue injected into the sac to show perforation
  3. Skin incisionCurvilinear along anterior lacrimal crest, 3-4 mm from medial canthusStraight, on side of nose 8-10 mm from medial canthuslength (10-12 mm); not extended above the medial canthus
  4. Dissection to periosteumblunt, through subcutaneous tissue and orbicularis
  5. Periosteum reflectedFreer elevator; anterior limb of medial canthal tendon cut
  6. Sac freedmedial wall from lacrimal fossa bluntly; lateral wall from orbicularis and periorbita with Westcott scissors; common canaliculus cut from sac
  7. Sac removedAmputated at the junction with the nasolacrimal ductTwisted off from the NLD with artery forcepsfor tumour, as far down the duct as possible
  8. Remnants dealt withCommon canaliculus, NLD stump and remnant lining cauterisedBony NLD curetted
  9. Canaliculi cauterisedYes (instrument, mode)Nowhitening of punctum confirms
  10. Haemostasiscautery; bone wax or gel foam if needed

Closure, drains and dressing

  1. Medial canthal tendon / periosteumsutured back or not
  2. Orbicularis6-0 polyglactin
  3. Skin6-0 silk / polypropylene / polyglactin
  4. DressingPatchNo patch

Specimens and implants

  1. Lacrimal sac for HPEgross look recorded (mass, discolouration, missing wall); formalin; side labelled; for tumour, margins sent separately
  2. CultureNot sentSent: sac contents (reason)record either way

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. Patchremove on day 1
  2. Wound careclean with povidone-iodine 5% from day 1
  3. Topical antibioticdrug, frequency
  4. Oral analgesicdrug, dose, frequency
  5. Oral antibioticonly for extended DCT or as indicated
  6. Watch forswelling, bleeding, pain behind the eye, drop in vision (orbital haematoma)
  7. Suture removalat 1 week, stop medicines
  8. Next surgeryplanned eye operation (e.g. cataract) and when
  9. HPE reportdate to collect

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: Mrs. K.B., 72 years, with right chronic dacryocystitis (mucopurulent regurgitation on pressure over the sac) and a mature cataract in the same eye; watering does not trouble her much. On long-term treatment for heart failure.

Case details

Date: 10/09/2026. Elective. OT 2. Start 11:15. End 11:55.

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

Anaesthetist: Dr D. (monitoring). Scrub nurse: Sr E.

Indication and pre-op

Indication: right chronic dacryocystitis in a frail elderly patient with heart disease, needing cataract surgery. DCT chosen over DCR because it is quicker under local anaesthesia with less bleeding; epiphora is not her main complaint.

Regurgitation of mucopus on pressure over the right sac. Syringing: regurgitation from the upper punctum, hard stop. Canaliculi patent. No sac mass felt; imaging not needed.

Not on anticoagulants. Bleeding time, clotting time and PT/INR normal. BP 134/80 mmHg. Physician and anaesthetist fitness for local anaesthesia with adrenaline 1:200000 recorded.

Consent: procedure-specific consent taken in Telugu with patient and son, including that watering will continue, bleeding and scar.

Right side marked. WHO checklist done. Systemic antibiotic not given.

Anaesthesia and position

Supine. 2% lignocaine with 0.5% bupivacaine with adrenaline 1:200000. Infratrochlear block with 2 ml, then infiltration along the anterior lacrimal crest down to periosteum above and below. Proparacaine drop to the right eye. Painted with povidone-iodine and draped.

Findings

Sac moderately distended with mucopus, wall thickened. No mass or discolouration. Removed whole. Periorbita intact. Angular vein not seen in the field.

Procedure

Curvilinear incision 11 mm long, 4 mm medial to the medial canthus along the anterior lacrimal crest, not carried above the canthus.

Blunt dissection through subcutaneous tissue and orbicularis to the periosteum.

Periosteum lifted with a Freer elevator and reflected laterally. Anterior limb of the medial canthal tendon cut. Medial wall of the sac separated bluntly from the lacrimal fossa.

Lateral wall freed from orbicularis and periorbita with Westcott scissors. Common canaliculus cut from the sac. Superior and posterior walls freed down to the nasolacrimal duct.

Sac amputated at its junction with the nasolacrimal duct.

Common canalicular opening, NLD stump and remaining lining cauterised. Canaliculi cauterised with a probe; punctum whitened.

Haemostasis secured with cautery.

Closure

Orbicularis closed with 6-0 polyglactin 910 (Vicryl). Skin closed with interrupted 6-0 silk.

Antibiotic ointment. Patch applied.

Specimens and implants

Right lacrimal sac, whole, about 12 x 8 mm, in formalin, sent for HPE. Gross: thick wall, mucopus, no mass. No implant.

End of procedure

Blood loss about 10 ml. Swab and needle count correct.

No intra-operative complications. Pulse 76/min, BP 140/84 mmHg. Sent to ward.

Post-op orders

Patch off on day 1. Wound cleaned with povidone-iodine 5% daily.

Topical antibiotic drops and ointment to the wound as charted. Oral paracetamol as charted.

Inform doctor at once if swelling, bleeding, pain behind the eye or blurred vision.

Skin sutures out at 1 week, then stop medicines.

Right cataract surgery to be planned after the wound heals. Collect HPE report at the suture removal visit.

Signature

Dr A., JR-2, Ophthalmology. Reg. no. ________. 10/09/2026, 12:10.

Must document for this operation

  • Why DCT and not DCR was chosen. DCT is done only for set indications, and the reason protects the surgeon if the patient later complains of watering.
  • That the patient was told watering will continue. Persistent watering is the expected result, not a complication, and the consent record must show this.
  • Whether the sac came out whole and how remnants were treated (cautery or curettage). Recurrent infection usually comes from a sac remnant, and the next surgeon needs to know what was done.
  • Gross appearance of the sac and that it was sent for histopathology (HPE). Unexpected tumours, TB and granulomatous disease are found only on HPE.
  • Whether the periorbita stayed intact. A breach raises the risk of orbital haematoma and cellulitis, and should be known if the patient complains of pain or visual loss.
  • Canaliculi cauterised or not. This decides the options for a later bypass operation.

Common mistakes in these notes

  • Not writing the reason for choosing DCT over DCR.
  • No record that the sac was removed whole.
  • Not sending the sac for histopathology (HPE).
  • Not recording the anaesthetic drugs and volumes used for the nerve blocks.
  • No plan written for the eye operation that the DCT was done for.

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))
  • Tissue not sent for HPE is human anatomical waste and goes in the yellow bag. Discarded formalin is yellow (f) chemical waste. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)
  • 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. (NABH 5th ed., COP.14(e) and (f))

Sources

  • Ali MJ, ed. Principles and Practice of Lacrimal Surgery. Springer India; 2015, Ch 34, Dacryocystectomy: Indications and Techniques (Ali MJ), pp. 327-334.
  • Khurana AK, Khurana AK, Khurana B. Comprehensive Ophthalmology. 6th ed. Jaypee Brothers; 2015, Ch 16, Diseases of Lacrimal Apparatus: chronic dacryocystitis treatment, external DCR steps 1-4 and 9, surgical technique of DCT, pp. 395-398.

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

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