OT notes · Ophthalmology

Entropion and ectropion repair

Usual anaesthesia
Local: infiltration of lignocaine 2% with adrenaline 1:100000 into the lid and lateral canthus, with topical anaesthetic drops
Position
Supine
Setting
elective

Operative note template for correction of entropion or ectropion of the eyelid, with a filled example for a lateral tarsal strip done for involutional lower lid ectropion under local anaesthesia.

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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

  • under-correction
  • over-correction
  • recurrence and need for further surgery
  • change in lid shape or contour, rounding of the outer corner
  • bleeding and haematoma behind the eye (rare)
  • wound infection and suture granuloma
  • dry eye or persistent watering
  • injury to the tear duct in medial surgery

Pre-operative details for this operation

  1. DiagnosisInvolutional entropionCicatricial entropion (trachoma, chemical injury, SJS, pemphigoid)Congenital entropionInvolutional ectropionCicatricial ectropionParalytic ectropionMechanical ectropion
  2. Lid and sideRight upperRight lowerLeft upperLeft lower
  3. Gradeentropion I-III (posterior border / intermarginal strip / whole margin); ectropion I-III (punctum only / conjunctiva seen / fornix seen)
  4. Horizontal laxitydistraction test in mm (more than 6 mm is significant); snap-back test
  5. Canthal tendonsmedial: lateral punctal pull test; lateral: canthal rounding, movement on medial pull
  6. Punctum position and patencyeverted / apposed; stenosis; syringing
  7. Corneaabrasion, punctate staining, ulcer, vascularisation
  8. Cause-related historytrachoma, chemical injury, glaucoma drops, facial palsy, previous lid surgery, skin scars
  9. Anticoagulant / antiplatelet historydrug, stopped or continued

Anaesthesia and position

  1. AnaesthesiaLocal infiltration + topical dropsLocal with monitored sedationGeneral (child, graft harvest)drug, strength, adrenaline
  2. PositionSupine

Operative findings

  1. Main cause found at surgeryHorizontal laxityLower lid retractor disinsertionOver-riding preseptal orbicularisScarred / thickened tarsusScarred conjunctiva (posterior lamella short)Skin shortage (anterior lamella short)Medial canthal tendon laxity
  2. Amount of lid shortenedmm of tarsus or wedge removed
  3. Punctum after correctionApposed to globeStill everted

Procedure (steps)

  1. Painting and drapingantiseptic used
  2. Procedure chosenEverting (Quickert) suturesWies transverse blepharotomy with everting suturesRetractor plication + horizontal tighteningTarsal rotation / modified Ketssey (upper lid cicatricial)Posterior lamellar graft (mucous membrane)Lateral tarsal stripMedial spindle (medial conjunctivoplasty)Full-thickness pentagonal wedge (horizontal shortening)Kuhnt-Szymanowski (Byron Smith / Foulds modification)V-Y plasty / Z-plastyScar excision + full-thickness skin graft
  3. Traction suturegrey line, suture size; lid everted over a lid plate if posterior approach
  4. Incisionsite (grey line, subciliary, sulcus subtarsalis, lateral canthus, conjunctival ellipse), distance from margin in mm, blade
  5. Lateral canthotomy and inferior cantholysis (if horizontal tightening)skin incision length; scissors used
  6. Amount of shortening markedlid pulled laterally, overlap marked on the margin; mm removed
  7. Tarsal strip fashionedmargin and lash follicles removed along the strip; conjunctiva, retractors and orbicularis trimmed; conjunctiva on strip cauterised
  8. Retractors / tarsus / everting suturesnumber of sutures, material and size, where they exit on the skin (mm below or above the lash line)
  9. Fixation to periosteumsuture material and size, needle; fixed inside the lateral orbital rim at Whitnall's tubercle; tension
  10. Canthal angle reformedcerclage suture through upper and lower grey line
  11. Graft (if used)type (mucous membrane, skin), donor site, size in mm, fixation
  12. Lid position checkedmargin against globe; punctum position; lid distracts about 1 mm after tightening

Closure, drains and dressing

  1. Orbicularissuture or not
  2. Skinsuture material and size
  3. Frost suture / bolsterNoneFrost suture to foreheadBolster over graft
  4. Ointment and dressingdrug; pressure dressing; for how long

Specimens and implants

  1. Tissue removedDiscardedSent for HPE (reason)tarsal strip / wedge / scar
  2. Graftdonor site and size, if any

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 or pressure dressing; remove when (usually next morning)
  2. Topical antibiotic ointmentto wound and eye: drug, frequency, duration
  3. Analgesiaoral drug, dose, frequency
  4. Watch forincreasing pain, swelling, bleeding, reduced vision (orbital haematoma)
  5. Anticoagulant restartwhen
  6. Everting / non-absorbable suturesremoval day if used; absorbable skin sutures need no removal
  7. Frost suture removalday, if placed
  8. Reviewdate; check lid position, cornea and punctum

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. L.D., 71 years, with watering and redness of the left eye for 1 year due to involutional ectropion of the left lower lid, grade II, with marked horizontal laxity and a normal medial canthal tendon.

Case details

Date: 21/05/2026. Elective. OT 3. Start 09:40. End 10:25.

Surgeon: Dr A. (3rd-year resident, Ophthalmology). Assistant: Dr B. Consultant: Dr C., present.

Anaesthesia: local by surgeon, with anaesthetist Dr D. monitoring. Scrub nurse: Sr E.

Indication and pre-op

Indication: left lower lid involutional ectropion, grade II (lid margin everted, palpebral conjunctiva visible), with epiphora and chronic conjunctival redness.

Distraction test 9 mm. Snap-back test: lid returns only after 2 blinks. Lateral canthus rounded. Lateral punctal pull test: punctum moves 2 mm, medial canthal tendon normal. Punctum everted, improved when the lid is pulled laterally. Syringing patent.

Cornea: inferior punctate staining. No trachoma scarring, no facial palsy, no skin scar.

On aspirin 75 mg, continued after physician advice. BP controlled.

Consent: procedure-specific consent taken in Gujarati, including under- and over-correction, recurrence and rounding of the outer corner.

WHO checklist done. Left eye marked.

Anaesthesia and position

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

Procedure

Lateral tarsal strip, left lower lid.

5 mm skin incision above the horizontal raphe lateral to the canthus with a No. 15 blade. Lateral canthotomy done. Inferior crus cantholysis with straight iris scissors.

Lid pulled laterally. Point where it met the cut edge of the upper lid marked on the lower lid margin. Amount to shorten: 6 mm.

Lid margin denuded up to the mark and lash follicles removed along the strip. Conjunctiva, retractors and orbicularis trimmed to leave a squared-off tarsal strip. Conjunctiva on the strip cauterised.

5-0 polyglycolic acid suture on a semicircular needle passed twice through the strip, then through the periosteum just inside the lateral orbital rim at the level of Whitnall's tubercle.

6-0 plain gut cerclage suture passed through the cut edge and grey line of the lower lid and the grey line and cut edge of the upper lid, and tied to reform a sharp canthal angle.

Strip suture tied so that the lower lid could be pulled about 1 mm from the globe. Lid margin now against the globe. Punctum apposed. No medial spindle needed.

Closure

Skin closed with interrupted 6-0 plain gut.

Antibiotic ointment to the eye and wound. Pad and light pressure dressing.

Specimens and implants

Excised lateral lid margin and skin, 6 mm: discarded as yellow bag waste. No HPE (no suspicious lesion). No implant.

End of procedure

Blood loss about 5 ml. Swab and needle count correct.

No intra-operative complications. Pulse 84/min, BP 142/86 mmHg. Shifted to ward.

Post-op orders

Pressure dressing off next morning.

Antibiotic eye ointment to the wound and eye as charted.

Oral paracetamol as charted if needed for pain.

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

Skin sutures absorbable: no removal needed.

Review in the oculoplasty OPD on day 7 for lid position, cornea and punctum.

Signature

Dr A., JR-3, Ophthalmology. Reg. no. ________. 21/05/2026, 10:40.

Must document for this operation

  • Type and cause of the malposition (involutional, cicatricial, paralytic, congenital) and the lid. The operation chosen depends on the cause, and a reviewer can judge the choice only if the cause is written.
  • Laxity tests with numbers (distraction in mm, snap-back, punctal pull). These justify horizontal tightening and are the baseline if the lid drops again.
  • Exact procedure and amount of tissue removed in millimetres. A surgeon doing a redo needs to know how much lid is left and what was already done.
  • Suture material, where the everting sutures exit, and fixation point for a tarsal strip. Over- or under-correction is traced to suture placement and tension, so these must be on record.
  • Punctum position at the end. Watering after surgery can then be sorted into punctal malposition or blockage.
  • Anticoagulant status and haemostasis. Orbital haematoma is a recognised complication and the note should show the risk was handled.

Common mistakes in these notes

  • Writing 'entropion correction done' with no named procedure.
  • Not recording the laxity tests, so the need for horizontal tightening cannot be judged.
  • Not stating whether the upper or lower lid was operated.
  • In trachomatous entropion, not recording trichiasis and corneal scarring before surgery.
  • No plan for removal of non-absorbable everting sutures.

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. (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

  • Albert DM, Lucarelli MJ, eds. Clinical Atlas of Procedures in Ophthalmic and Oculofacial Surgery. 2nd ed. Oxford University Press; 2012, Ch 76, Entropion (Meyer DR, Dewan MA), pp. 792-799.
  • Albert DM, Lucarelli MJ, eds. Clinical Atlas of Procedures in Ophthalmic and Oculofacial Surgery. 2nd ed. Oxford University Press; 2012, Ch 78, Ectropion (Winn BJ, Sires BS), pp. 807-820.
  • Albert DM, Lucarelli MJ, eds. Clinical Atlas of Procedures in Ophthalmic and Oculofacial Surgery. 2nd ed. Oxford University Press; 2012, Ch 77, Lower Eyelid Epiblepharon (Khwarg SI, Lee MJ): local anaesthetic, Fig 77.2, pp. 802.
  • Roper-Hall MJ. Stallard's Eye Surgery. 7th ed. Wright (Butterworths); 1989, Ch 3, The eyelids and reconstructive (plastic) surgery: Entropion and ectropion, pp. 104-110.
  • Khurana AK, Khurana AK, Khurana B. Comprehensive Ophthalmology. 6th ed. Jaypee Brothers; 2015, Ch 15, Disorders of Eyelids: entropion and ectropion, pp. 371-376.
  • Roper-Hall MJ. Stallard's Eye Surgery. 7th ed. Wright (Butterworths); 1989, Ch 3, Minor surgery: topical and local anaesthesia for lid margin surgery, 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.

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