Glaucoma drainage device (Ahmed valve) implantation

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

• eye pressure too low (hypotony), shallow anterior chamber, choroidal detachment
• suprachoroidal haemorrhage (rare) and loss of vision
• high pressure phase weeks after surgery, needing drops
• tube touching the cornea or lens; corneal swelling
• tube blocked by iris, vitreous, blood or fibrin
• tube or plate exposure through the conjunctiva, needing repair
• infection inside the eye (endophthalmitis)
• double vision or restricted eye movement
• bleeding into the front of the eye (hyphaema)
• block-related: bleeding behind the eye, globe perforation (rare)

Pre-operative details for this operation

1. EyeRightLeft
2. IndicationFailed trabeculectomyNeovascular glaucomaUveitic glaucomaScarred conjunctiva / previous surgeryPost-keratoplasty / post-retinal surgeryOther refractory glaucomaIOP on how many drugs, visual acuity, field and disc status
3. Lens status and AC depthPhakicPseudophakicAphakicprevious vitrectomy, silicone oil
4. Quadrant plannedSuperotemporalInferotemporalSuperonasalInferonasalconjunctiva free and mobile in that quadrant
5. Device and patch graft availablemodel and size of valve; patch material (donor sclera, processed pericardium, other)
6. Anticoagulants / antiplateletsstopped or continued, decided with physician
7. Eye markedYes

Anaesthesia and position

1. AnaesthesiaPeribulbar blockRetrobulbar blockGeneraldrug, concentration, volume
2. Traction sutureCorneal (clear cornea near limbus)Scleralmaterial and size, e.g. polyglactin or silk 6-0 / 7-0 on a spatulated needle
3. PositionSupine

Operative findings

1. Conjunctiva and Tenon's in the chosen quadrantscarring, thin, previous bleb
2. Sclerathinning
3. Valve primingPrimed, flow seenDifficult to prime
4. Tube position at endlength in AC (mm), clear of cornea and iris, bevel direction
5. AC depth at endDeepShallowFormed with viscoelastic

Procedure (steps)

1. Conjunctival incisionFornix basedLimbus basedquadrant and extent in clock hours
2. Sub-Tenon pocketblunt dissection between the recti with Westcott and Stevens scissors
3. Valve primedBSS through the tube with a 27 or 30 G cannula
4. Plate fixed to scleradistance of anterior edge from limbus (mm) by calipers; number of sutures, material (nylon / silk / polypropylene 8-0 or 9-0); valve body not grasped with forceps
5. AntimetaboliteNoneMitomycin C (concentration, time)
6. Tube trimmedbevel up; planned length in AC (mm)
7. Entry into AC23 G needle trackPars plana (with vitrectomy)Sulcusdistance behind limbus, parallel to iris
8. Tube inserted and securedsuture to sclera: material, e.g. nylon 9-0 or 10-0
9. Viscoelastic in ACNot usedUsed (why)
10. Patch graft over tubematerial, size, sutures (nylon 9-0 / 10-0)

Closure, drains and dressing

1. Conjunctivamaterial and pattern, e.g. nylon 10-0, or polyglactin 8-0 / 9-0 on a tapered needle; tube and patch fully covered
2. Traction suture removed
3. Subconjunctival injectionsteroid and antibiotic: drugs and doses
4. Pad and shieldYes

Specimens and implants

1. Drainage devicemake, model (e.g. Ahmed FP7 / S2), lot and serial number; sticker pasted
2. Patch graftmaterial, source (eye bank ID or manufacturer lot)

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. IOP and AC depthday 1 and each visit; watch for hypotony and a shallow chamber
2. Topical steroiddrug and frequency; anti-inflammatory cover usually continued for months
3. Topical antibioticdrug, frequency, duration
4. Glaucoma drugswhich continue and which stop in the operated eye, as decided by the consultant and written on the drug chart; aqueous suppressants restarted if IOP rises in the high-pressure phase
5. Tube checkposition, patency, contact with cornea or lens at each visit
6. Activityavoid rubbing the eye; report pain, redness or drop in vision
7. Follow-upday 1, then as per glaucoma clinic schedule

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