OT notes · Ophthalmology

Repair of eyelid laceration (lid margin / canalicular)

Usual anaesthesia
General for canalicular or complex lacerations (local infiltration can distort the medial canthus); local infiltration for simple lid margin tears
Position
Supine
Setting
emergency

Operative note template for repair of an eyelid laceration involving the lid margin, with or without the canaliculus, with a filled example for a full-thickness lower lid margin and lower canalicular laceration repaired with bicanalicular silicone intubation under general 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

  • watering if the canaliculus scars or blocks
  • notching of the lid margin
  • lid retraction, turning in or out of the lid
  • incomplete lid closure and exposure of the cornea
  • tube problems: slipping out, rubbing the eye, granuloma, splitting of the punctum
  • need for a second operation (DCR or tube removal under anaesthesia)
  • infection, especially after bites
  • visible scar, lash loss or in-turned lashes

Pre-operative details for this operation

  1. Mode and time of injuryobject, bite (animal/human), road traffic accident, assault; hours since injury
  2. Globe injury ruled outvisual acuity, anterior segment, fundus; record the findings
  3. Wound descriptionlid, side, full or partial thickness, margin involved, position relative to punctum, tissue loss
  4. CanaliculusNot involvedLower cutUpper cutBoth cutwound medial to the punctum is a canalicular injury until proved otherwise; probing / irrigation result
  5. Canthal tendonsIntactMedial avulsedLateral avulsedtelecanthus?
  6. Orbital fat seen / levator cutNoFat prolapseLevator cut
  7. CT orbit / faceNot neededDone: no fractureDone: fracture / foreign body (details)
  8. Tetanus prophylaxisgiven, time
  9. Systemic antibioticby nature of wound (bite, contaminated)

Anaesthesia and position

  1. AnaesthesiaGeneralLocal infiltration (simple margin tear)reason if local for a canalicular injury
  2. PositionSupine
  3. MagnificationLoupesOperating microscope
  4. Nasal decongestionNasal pack with decongestantNot done

Operative findings

  1. Length and depth of lacerationmm; layers involved
  2. Cut ends of canaliculusdistal end found (white ring of canalicular wall); proximal end found how (direct view, pigtail probe, irrigation through the other punctum)
  3. Distance of canalicular cut from punctummm
  4. Foreign bodyNoneRemoved (describe)
  5. Tissue lossNonePresent (mm)
  6. Septum / orbital fat / levatorseptum left open

Procedure (steps)

  1. Wound cleaningsaline irrigation; debris and foreign body removed; minimal handling and cautery
  2. Proximal cut end identifiedmethod used; Bowman probe confirms hard stop
  3. Canalicular intubationBicanalicular with nasolacrimal duct (Crawford / Ritleng / Quickert-Dryden)Pigtail bicanalicular (no NLD)Monocanalicular (Mini-Monoka)Not neededtube retrieved from the inferior meatus; how
  4. Canalicular / pericanalicular sutures7-0 polyglactin to canalicular edges at several sites (Albert atlas)Pericanalicular mattress with PDS, 6-0 proximal and 5-0 distal (Ali, Lacrimal Surgery)number, material and size; tied with gentle traction on the tube
  5. Medial canthal tendon5-0 polyglactin (Albert atlas)4-0 polyglactin (Ali, Lacrimal Surgery)Not neededre-approximated before the lid margin is closed: suture size
  6. Lid margin aligned3 sutures: posterior lid line (meibomian orifices), grey line, lash line; 6-0 silk; ends left long
  7. Tarsus closedpartial-thickness 6-0 polyglactin sutures along the height of the tear
  8. Levator repaired (if cut)suture
  9. Orbicularis closed6-0 or 7-0 polyglactin; orbital septum not closed
  10. Tube securedknot below inferior meatus, number of knots; tube lies loosely at medial canthus

Closure, drains and dressing

  1. Skinsuture material and size
  2. Margin suture endsanchored to the lid skin away from the cornea
  3. Ointment and dressingdrug; pad

Specimens and implants

  1. Silicone stenttype, make, lot number, sticker in case sheet
  2. Foreign bodykept / sent / handed over if medicolegal

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. Topical dropsantibiotic-steroid drops, tapering over 3 to 4 weeks; check IOP if on steroid
  2. Topical antibiotic ointmentto the wound, continued for a week after suture removal
  3. Systemic antibioticonly if bite, contaminated or industrial wound: drug, dose, duration
  4. Nasal decongestantfirst few weeks, drug and frequency
  5. Analgesiadrug, dose, frequency
  6. Tube carereport if the loop is visible or slipping
  7. Suture removaldate for skin and lid margin sutures
  8. Stent removalplanned date: up to 3 months (Ali, Lacrimal Surgery) or 3 to 6 months (Albert atlas)
  9. Patency check after stent removalfluorescein dye disappearance test, irrigation
  10. MedicolegalMLC number if applicable

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. V.P., 26 years, fell from a motorcycle 8 hours ago, with a full-thickness laceration of the right lower lid margin 3 mm medial to the punctum, cutting the lower canaliculus. Globe intact.

Case details

Date: 03/07/2026. Emergency. OT 4. Anaesthesia start 20:10. Wound exploration 20:25. End 21:35.

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

Anaesthetist: Dr D. Scrub nurse: Sr E.

MLC no. ______ registered in casualty.

Indication and pre-op

Road traffic accident at 12:00 today. Full-thickness laceration of right lower lid, through the margin 3 mm medial to the lower punctum. Probe passed through the lower punctum came out in the wound: lower canalicular laceration. Upper canaliculus intact on probing.

Right eye: vision 6/9, no globe wound, anterior chamber normal, fundus normal. Left eye normal.

No orbital fat in the wound. CT face and orbit: no fracture, no foreign body.

Tetanus toxoid given in casualty at 13:30. Nil orally since 12:30.

Consent: procedure-specific and anaesthesia consent taken in Marathi from the patient, including persistent watering, tube problems and a second operation.

WHO checklist done. Right side marked. IV antibiotic given at induction as charted by the anaesthetist.

Anaesthesia and position

General anaesthesia with endotracheal tube. Supine. Right nasal cavity packed with decongestant-soaked cotton. Face painted with povidone-iodine and draped. Loupes and headlight.

Findings

Full-thickness laceration 12 mm long, lid margin to below the tarsus. Lower canaliculus cut 3 mm medial to the punctum. Distal (punctal) segment probed through the lower punctum. Proximal (medial) cut end seen as a white ring of canalicular wall. No tissue loss. No foreign body. Septum intact.

Procedure

Wound irrigated with saline. No debridement needed. Cautery kept to a minimum.

Proximal (medial) cut end found by direct view with the lid edges approximated, confirmed with a Bowman probe (hard stop).

Bicanalicular silicone intubation (Crawford type): upper probe passed through the upper punctum and canaliculus into the nose; lower probe through the lower punctum, distal and proximal cut ends, into the nose. Both ends retrieved from the inferior meatus with the Crawford hook.

Canalicular edges closed with three interrupted 7-0 polyglactin 910 (Vicryl) sutures, tied with gentle traction on the tube.

Medial canthal support secured with 5-0 polyglactin before the lid margin was closed.

Lid margin aligned with three 6-0 silk sutures at the posterior lid line, grey line and lash line, ends left long.

Tarsus closed with two partial-thickness 6-0 polyglactin sutures, the upper one close to the margin.

Orbicularis closed with 6-0 polyglactin. Orbital septum not sutured.

Tube ends tied with a single knot below the inferior meatus. Loop lying loosely at the medial canthus.

Closure

Skin closed with 6-0 fast-absorbing plain gut.

Margin silk ends anchored to the lid skin below, away from the cornea.

Antibiotic ointment. Pad applied. Nasal pack removed.

Specimens and implants

Implant: bicanalicular silicone stent (Crawford type). Make and lot no. ______. Sticker pasted in the case sheet.

No specimen. No foreign body.

End of procedure

Blood loss about 15 ml. Swab, needle and instrument count correct.

No intra-operative complications. Extubated, shifted to recovery. Pulse 88/min, BP 122/78 mmHg.

Post-op orders

Pad off next morning. Antibiotic-steroid eye drops, tapering over 4 weeks. IOP check at the 2-week visit.

Antibiotic ointment to the wound, continued for a week after suture removal.

Nasal decongestant drops for 2 weeks, as charted. Oral paracetamol as charted.

Report if the tube loop is seen or slips.

Review in the oculoplasty OPD in 1 week; margin silk sutures removed on the date the consultant decides. Stent removal planned at 3 months, then fluorescein dye test and irrigation.

MLC papers completed with the injury details.

Signature

Dr A., JR-3, Ophthalmology. Reg. no. ________. 03/07/2026, 21:50.

Must document for this operation

  • Time and mode of injury and time of repair. Canalicular repair is best done within 24 to 48 hours, and the delay affects the result and any medicolegal case (MLC) opinion.
  • Globe examination findings before repair. A missed open-globe injury is the worst outcome, and the note must show it was looked for.
  • Whether the canaliculus was cut, how the proximal end was found, and the distance from the punctum. If the patient waters later, the next surgeon needs this to plan a secondary operation.
  • Type of stent, make and lot number, and how it was secured (number of knots). With a single small knot the tube can be removed in the OPD; with several knots it has to come out through the nose.
  • Layer-by-layer closure, with the septum left open. Lid retraction after repair is traced to septal closure or anterior lamella shortening.
  • Planned stent removal date. Tight or long-forgotten stents can cause granuloma and cheese-wiring of the punctum.
  • Tetanus prophylaxis and antibiotic given. These are checked in audits of trauma cases.

Common mistakes in these notes

  • Writing 'lid tear sutured' without saying whether the canaliculus was involved.
  • Not recording the globe examination before the repair.
  • No stent details or sticker, and no date for removal.
  • Not noting the medicolegal case (MLC) number for an assault or road traffic injury.
  • Recording only the skin closure and not the lid margin and tarsal sutures.

Indian practice and paperwork

  • Tetanus prophylaxis should be given if indicated. Record it in the note or the pre-op checklist. (NQAS Assessor's Guidebook for District Hospitals (2020), ME E15.2)
  • 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. Record the silicone stent the same way. (NABH 5th ed., MOM.10(d))
  • Consent must explain the procedure, risks, alternatives and who will do it, in a language the patient understands. (NABH 5th ed., PRE.4(c))
  • An unsigned record, or one written after discharge, has little legal value. Corrections are made by striking through the whole line and rewriting it with date and time. (Thomas J. Medical records and issues in negligence. Indian J Urol 2009;25(3):384-8)

Sources

  • Albert DM, Lucarelli MJ, eds. Clinical Atlas of Procedures in Ophthalmic and Oculofacial Surgery. 2nd ed. Oxford University Press; 2012, Ch 96, Eyelid and Canalicular Trauma (Burkat CN, Punja KG, Kim N), pp. 1002-1014.
  • Ali MJ, ed. Principles and Practice of Lacrimal Surgery. Springer India; 2015, Ch 16, Lacrimal Trauma and Its Management (Sundar G), pp. 159-170.

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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