OT notes · Ophthalmology

Evisceration / enucleation (with or without implant)

Usual anaesthesia
Evisceration: local (retrobulbar block) in adults. Enucleation: local in adults or general (Stallard prefers general); general anaesthesia in children
Position
Supine
Setting
elective

Operative note template for evisceration or enucleation of the eye, with or without an orbital implant, with a filled example for evisceration with a silicone implant for a blind painful eye 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

  • removal of the eye is permanent: no vision in that eye afterwards
  • bleeding and orbital haematoma
  • infection of the socket or implant
  • implant exposure, extrusion or need for removal
  • sympathetic ophthalmia in the other eye (higher after evisceration)
  • hidden tumour found in the removed tissue (after evisceration)
  • shallow fornices, socket contraction and poor artificial eye fit
  • lid drooping or turning out

Pre-operative details for this operation

  1. OperationEvisceration with implantEvisceration without implant (frill, for infection)Enucleation with implantEnucleation without implantEnucleation for eye donation (cadaver)
  2. Eye to be removedRightLeftconfirmed with patient, notes, imaging and examination; marked
  3. IndicationBlind painful eyePanophthalmitis / endophthalmitisSevere trauma, no perception of lightIntraocular tumour (retinoblastoma, melanoma)Phthisis with cosmetic deformityAnterior staphyloma
  4. Visionoperated eye (confirm no perception of light) and fellow eye
  5. Tumour excluded (evisceration)B-scan / CT: no massNot possible (media opaque, no imaging): reasonevisceration is avoided if a tumour cannot be ruled out
  6. Sympathetic ophthalmia risk discussedYes
  7. Implant size plannedaxial length of fellow eye (mm); evisceration implant = AL - 3, enucleation implant = AL - 2
  8. Implant and conformer availablematerial and sizes

Anaesthesia and position

  1. AnaesthesiaRetrobulbar blockSubconjunctival local infiltrationGeneralGeneral with retrobulbar (retro-ocular) injection for haemostasisdrugs, strengths, adrenaline, volume
  2. PositionSupine
  3. Operative eye confirmed at time outmark; phenylephrine drop dilates the operative pupil as a marker

Operative findings

  1. Globesize, cornea, perforation, staphyloma, pus
  2. Intraocular contentspus, blood, lens, uvea; any mass
  3. Scleraintact / thinned / perforated
  4. Optic nerve stump (enucleation)length, appearance
  5. Conjunctiva and Tenon'shealthy / scarred / deficient

Procedure (steps)

  1. Painting and draping; speculumantiseptic
  2. Limbal peritomy360 degrees, spring or Westcott scissors; conjunctiva and Tenon's preserved
  3. Evisceration: cornea excisedat or just beyond the limbus; whole cornea removed
  4. Evisceration: contents removedevisceration spatula and scoop; inner sclera scraped; absolute alcohol swab to residual uvea
  5. Evisceration: scleral incisionsPosterior scleral opening + anterior relaxing incisions (implant behind posterior sclera)Frill: sclera excised leaving 3 mm around optic nerve (no implant)Implant inside scleral shell
  6. Enucleation: sub-Tenon's dissectionfour quadrants cleared with blunt scissors
  7. Enucleation: recti tagged and cutsuture on each rectus (material, size) before disinsertion; obliques cut or tagged
  8. Enucleation: optic nerve cuttraction on muscle stumps; enucleation scissors from the medial side; length of nerve taken (long for tumour)
  9. Haemostasispressure pack, bipolar to optic nerve / stump
  10. Implantmaterial, diameter in mm, make, lot; wrap if any; soak (porous); introducer used
  11. Implant coverposterior sclera then anterior sclera (evisceration), or recti sutured to implant / wrap (enucleation); suture used
  12. Tenon's closedlayers, suture

Closure, drains and dressing

  1. Conjunctivasuture material and size; running / interrupted
  2. ConformerPlaced (size)Not placed
  3. Temporary tarsorrhaphyYesNo
  4. Ointment and pressure dressingduration of pressure patch

Specimens and implants

  1. Specimen for HPEEnucleation: whole globe with optic nerve (length marked), formalin, side labelledEvisceration: intraocular contents sent for HPE (surgeon's decision; reason)Evisceration: contents not sent (reason); discarded as anatomical wastethe books give no rule on HPE of evisceration contents; occult malignancy is a listed risk of evisceration
  2. Specimen for culturesmear and culture of the contents in panophthalmitis / endophthalmitis
  3. Orbital implantmaterial, diameter, make, lot, sticker
  4. Conformersize

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. Pressure dressingkeep for the planned days (often 3 days after evisceration); then open
  2. Pain controldrug, dose, frequency; severe pain or swelling needs review
  3. Antibioticssystemic and topical: drug, dose, duration (longer course for infection)
  4. Antiemetic / steroidif given
  5. Watch fororbital haematoma, fever, discharge, implant or conformer coming out
  6. Suturesabsorbable, or removal date for silk
  7. Tarsorrhaphy suture removaldate
  8. Other eyecheck vision at each visit; report any blurring, pain or redness (sympathetic ophthalmia)
  9. Artificial eyereferral for fitting after socket heals (about 6 weeks)
  10. 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: Mr. H.M., 58 years, with a blind painful left eye (no perception of light) from absolute glaucoma after a failed vitreoretinal surgery 3 years ago, with pain not controlled by drops. B-scan shows no intraocular mass.

Case details

Date: 18/08/2026. Elective. OT 1. Block 10:05. Incision 10:20. End 11:10.

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

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

Indication and pre-op

Indication: blind painful left eye. Left eye: no perception of light, IOP 48 mmHg on three drugs, corneal oedema, pain for 6 months. Right eye: 6/9, normal, axial length 23.5 mm.

B-scan left eye: no intraocular mass, old retinal detachment. Tumour considered and excluded as far as possible. Sympathetic ophthalmia risk explained.

Implant planned: 20 mm silicone sphere (fellow eye axial length 23.5 mm minus 3). 20 mm and 18 mm spheres and conformers in OT.

Consent: separate written consent for removal of the contents of the left eye with implant, taken in Kannada, with patient and wife. Risks explained, including permanent loss of the eye, implant exposure and sympathetic ophthalmia.

Left eye marked. Phenylephrine drop to the left eye. Left eye confirmed again at time out by surgeon, anaesthetist and nurse. WHO checklist done.

IV antibiotic given before incision as charted.

Anaesthesia and position

Supine. Retrobulbar block with 1% lignocaine and 0.25% bupivacaine with adrenaline 1:100000. Inj dexamethasone 8 mg IV by anaesthetist. Painted with povidone-iodine and draped. Speculum placed.

Findings

Cornea hazy and oedematous. Contents: old organised blood and detached retina. No mass seen. Sclera intact, of normal thickness. Conjunctiva and Tenon's healthy.

Procedure

Conjunctiva ballooned with local anaesthetic. 360-degree limbal peritomy with Westcott scissors, conjunctiva and Tenon's preserved.

Cornea excised at the limbus with Westcott scissors. Whole cornea removed.

Lens and uveal contents removed with the evisceration scoop. Inner sclera scraped clean. Residual uvea swabbed with absolute alcohol on a cotton-tipped applicator.

Posterior sclera opened with a diagonal incision. Optic nerve detached from the posterior sclera after bipolar cautery. Two anterior relaxing scleral incisions made perpendicular to the posterior opening.

Sizer passed through both scleral layers into the intraconal space: 20 mm fits.

20 mm silicone sphere placed behind the posterior sclera with an introducer, speculum removed for insertion.

Posterior sclera closed over the implant with interrupted 5-0 polyglactin 910 (Vicryl). Anterior sclera closed over it with buried interrupted 5-0 polyglactin. Tenon's closed in two layers with buried interrupted sutures.

Closure

Conjunctiva closed with running 6-0 plain gut.

Antibiotic ointment in the socket. Conformer (medium) placed. Temporary suture tarsorrhaphy with silk over bolsters. Pressure patch applied.

Specimens and implants

Specimen: intraocular contents of left eye in formalin, sent for HPE on the consultant's decision (occult tumour cannot be fully excluded on B-scan). Requisition: blind painful eye, rule out occult tumour.

Implant: silicone sphere 20 mm. Make and lot no. ______. Sticker pasted in the case sheet and OT implant register.

End of procedure

Blood loss about 20 ml. Swab, needle and instrument count correct.

No intra-operative complications. Pulse 82/min, BP 138/84 mmHg. Shifted to ward.

Post-op orders

Pressure patch for 3 days.

Oral antibiotic and analgesic as charted.

Inform doctor at once if severe pain, swelling or bleeding.

Tarsorrhaphy suture removal and socket check in the OPD, date given in discharge summary.

Right eye vision checked at each visit. Patient told to report blurring, pain or redness of the right eye at once.

Referral for artificial eye fitting after about 6 weeks. Collect HPE report at the 2-week visit.

Signature

Dr A., JR-3, Ophthalmology. Reg. no. ________. 18/08/2026, 11:25.

Must document for this operation

  • The eye removed, and how it was confirmed (marking, drop, time out). Removal of the wrong eye is a listed complication and can never be undone, so the checks must be on record.
  • How an intraocular tumour was excluded before an evisceration. Evisceration of an eye with a hidden melanoma spreads tumour cells, and the imaging done is the defence.
  • Visual status of both eyes, and that sympathetic ophthalmia was explained. Any later loss of vision in the other eye will be judged against this record.
  • Implant material, diameter, make and lot number. The implant is permanent, and exposure or recall needs the exact details (NABH implant record).
  • Whether tissue was sent for HPE or culture or discarded, and what was asked of the pathologist. An unexpected tumour or infection is found only if the tissue reaches the lab with a clear question, and the next doctor needs to know if it was not sent.
  • For enucleation for tumour: length of optic nerve removed. Optic nerve invasion at the cut end changes further treatment.

Common mistakes in these notes

  • Writing 'eye removed' without saying evisceration or enucleation.
  • Not recording the side confirmation at time out.
  • No implant size or sticker in the note.
  • Not recording the imaging used to exclude a tumour before evisceration.
  • Not sending the enucleated globe for histopathology (HPE), or not writing whether evisceration contents were sent or discarded.

Indian practice and paperwork

  • NABH requires the batch and serial number of an implantable device to be recorded in the medical record, the master logbook and the discharge summary. (NABH 5th ed., MOM.10(d))
  • 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 requires steps to prevent wrong site and wrong patient surgery. For removal of an eye, the side check should be written in the note. (NABH 5th ed., COP.14(d))
  • 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)

Sources

  • Albert DM, Lucarelli MJ, eds. Clinical Atlas of Procedures in Ophthalmic and Oculofacial Surgery. 2nd ed. Oxford University Press; 2012, Ch 83, Enucleation (Custer PL, Buchanan AG), pp. 870-877.
  • Albert DM, Lucarelli MJ, eds. Clinical Atlas of Procedures in Ophthalmic and Oculofacial Surgery. 2nd ed. Oxford University Press; 2012, Ch 84, Evisceration (Bohnsack BL, Nelson CC, Kahana A), pp. 878-889.
  • Khurana AK, Khurana AK, Khurana B. Comprehensive Ophthalmology. 6th ed. Jaypee Brothers; 2015, Ch 8, Diseases of Uveal Tract: panophthalmitis and frill evisceration, pp. 172-173.
  • Khurana AK, Khurana AK, Khurana B. Comprehensive Ophthalmology. 6th ed. Jaypee Brothers; 2015, Ch 12, Diseases of Retina: enucleation, surgical technique, pp. 307-308.
  • Roper-Hall MJ. Stallard's Eye Surgery. 7th ed. Wright (Butterworths); 1989, Ch 11, Traumatic surgery: evisceration (smear and culture of contents) and enucleation (anaesthesia), pp. 414, 416.

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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