Intracapsular cataract extraction (ICCE)

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

• vitreous loss and need for anterior vitrectomy
• rupture of the lens capsule, conversion to extracapsular removal
• lens or fragment falling into the vitreous
• raised eye pressure after surgery
• retinal detachment and cystoid macular oedema (higher than with extracapsular surgery)
• infection inside the eye (endophthalmitis)
• corneal swelling and astigmatism from the large incision
• anterior chamber IOL problems: corneal swelling later, need to remove or exchange the lens
• expulsive haemorrhage (rare)
• block-related: bleeding behind the eye, globe perforation (rare)

Pre-operative details for this operation

1. EyeRightLeft
2. Indication for ICCE rather than ECCE / SICSMarkedly subluxated lensDislocated lens in anterior chamberOther (state)extent of zonular loss in clock hours, phacodonesis, vitreous in AC
3. Type of cataractmature / hypermature / intumescent
4. Visual acuity, IOP, fundus or B-scanB-scan if no fundus view
5. Biometry and IOL powerkeratometry, axial length, formula, AC IOL power chosen
6. Lacrimal sac patency / regurgitation testPatent, no regurgitationRegurgitation present: surgery deferred
7. PupilDilatedConstricteddrops used
8. Eye markedYes

Anaesthesia and position

1. AnaesthesiaPeribulbar blockRetrobulbar with facial blockGeneraldrug, concentration, volume, compression time
2. PositionSupine, head straight

Operative findings

1. Lenssubluxated direction, clock hours of zonular loss, capsule intact / wrinkled
2. Vitreous in anterior chamberNonePresent before extractionProlapsed during surgery
3. Anterior chamber and irisdepth, iridodonesis, synechiae
4. Lens deliveredIntact in capsuleCapsule ruptured

Procedure (steps)

1. Superior rectus bridle suturematerial and size, e.g. silk 4-0
2. Conjunctival flapFornix basedLimbus basedNo flap (corneal section)haemostasis: wet-field cautery
3. Groove and sectionextent in clock hours or degrees (e.g. 9.30 to 2.30, 150 degrees), depth two-thirds; entry with blade or keratome; completed with corneoscleral scissors
4. Pre-placed suture12 o'clock pre-placedNot used
5. Peripheral iridectomy / iridotomyOneTwoSector iridectomyinstrument; patency confirmed by red reflex
6. ZonulolysisNot neededAlpha-chymotrypsin injected behind iris
7. Lens deliveryCryoextractionCapsule forceps (Arruga)Wire vectisSmith (Indian) expressioncryo temperature; which pole first
8. Vitreous managementNo vitreous lossAnterior vitrectomy (method)
9. Pupil constricted and iris repositedacetylcholine / pilocarpine, iris repositor
10. Anterior chamber formedAirBalanced salt solutionViscoelastic
11. Anterior chamber IOLmodel, power, size; inferior haptic to 6 o'clock angle, superior haptic to upper angle; position checked; or 'left aphakic' with reason
12. Viscoelastic removedYesNot used

Closure, drains and dressing

1. Section closednumber of sutures, material, e.g. 5 to 7 interrupted nylon 10-0, knots buried
2. Wound watertightYes
3. Conjunctival flapReposited with wet-field cauterySutured
4. Subconjunctival injectiondrugs and volumes
5. PadPad and bandagePad and shield

Specimens and implants

1. LensDiscarded as human anatomical wasteSent for HPE (reason)
2. IOLmake, model, type (AC IOL), power, size, batch / lot, serial; barcode sticker pasted in the note

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. Restlie quietly on the back for 2 to 3 hours
2. Painanalgesic drug, dose, route
3. Dressingpad removed next morning and eye examined
4. Antibiotic dropsfour times a day for 10 to 14 days
5. Steroid dropsprednisolone 3 to 4 times a day for 6 to 8 weeks, tapered
6. NSAID drops2 to 3 times a day for about 4 weeks
7. Anti-glaucoma covertimolol 0.5% twice a day for 7 to 10 days if ordered; IOP on day 1
8. Suturesremoval at 6 to 8 weeks
9. Spectaclesfinal refraction after suture removal

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