OT notes · Ophthalmology

Penetrating keratoplasty

Usual anaesthesia
Peribulbar block in adults; general in children and uncooperative patients
Position
Supine, head straight, eye centred under the operating microscope
Setting
elective

Operative note template for penetrating keratoplasty, with a filled example for an optical phakic graft for a healed central corneal scar under peribulbar block.

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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

  • graft rejection, needing long-term drops and sometimes a repeat graft
  • primary graft failure
  • infection of the graft or inside the eye
  • wound leak and suture problems (loose or broken sutures)
  • high or irregular astigmatism; glasses or contact lens still needed
  • raised eye pressure (glaucoma) after the graft
  • cataract or damage to the lens during surgery
  • recurrence of the original disease in the graft
  • transmission of infection from donor tissue (screened, very low)

Pre-operative details for this operation

  1. EyeRightLeft
  2. IndicationOpticalTectonicTherapeuticCosmeticdiagnosis, e.g. healed keratitis scar, keratoconus, bullous keratopathy, perforated ulcer
  3. Lens statusPhakicAphakicPseudophakic (PC / AC IOL)
  4. Corneal vascularisation, thinning, synechiaequadrants and depth of vessels; area of thinning to include in the trephination
  5. Lids, tear film, corneal sensationSchirmer's, lid closure; corrected before surgery
  6. IOP and posterior segmentIOP controlled; B-scan if no fundus view
  7. Herpes simplex historyNoYes: antiviral cover planned
  8. Donor tissue detailseye bank, donor ID, age, cause of death, death-to-preservation time, storage medium and date, endothelial cell count, serology screen
  9. Eye markedYes

Anaesthesia and position

  1. AnaesthesiaPeribulbar blockRetrobulbar with facial blockGeneraldrug, concentration, volume, compression time; eye soft before opening
  2. PupilConstricted with pilocarpineConstricted with intracameral acetylcholineNot constricted
  3. Globe fixationSuperior and inferior rectus traction suturesScleral support (Flieringa) ringFixation forceps only

Operative findings

  1. Host corneasize and depth of opacity, vessels, thinning, measured diameter
  2. Anterior chamber, iris, anglesynechiae divided or not, iris damage
  3. Lens / IOLclear, cataract, IOL type and position; vitreous in AC
  4. Donor buttonclarity, epithelium, any folds, medium clear or turbid

Procedure (steps)

  1. Traction sutures or support ringmaterial and position
  2. Paracentesissite, blade; viscoelastic or air into AC
  3. Visual axis and suture marksinked Sinskey hook / radial marker
  4. Donor button preparedpunched from the endothelial side on a cutting block; trephine size (mm); medium sent for culture
  5. Host trephinationHand-held trephineVacuum trephine (Hessburg-Barron)size (mm), depth before entry, centration
  6. AC entered and host button excisedblade used, right- and left-cutting corneal scissors, edge regular
  7. Intraocular workNoneSynechiolysisPeripheral iridectomyAnterior vitrectomyCataract extraction with IOL (triple)IOL exchange / removal
  8. Viscoelastic over iris and lensYes
  9. Donor placed and cardinal sutures4 cardinal sutures, 12 then 6 o'clock first; nylon 10-0
  10. Remaining suturesInterrupted onlyInterrupted plus runningRunning onlynumber of interrupted sutures, bites of running suture; knots buried
  11. AC reformed and wound testedBSS; viscoelastic washed out; watertight
  12. Keratoscopy at endsurgical keratometer mire shape; sutures adjusted

Closure, drains and dressing

  1. Support ring / traction sutures removedYesNot used
  2. Subconjunctival injectionantibiotic and steroid, drugs and doses
  3. Topical at enddrug
  4. Pad and shieldYes

Specimens and implants

  1. Host corneal buttonSent for HPESent for HPE and culture (microbiology)container, fixative, requisition
  2. Donor rim / storage mediumSent for cultureNot sent
  3. Donor tissue recordeye bank label / donor ID sticker pasted in the note
  4. IOL (if inserted)type, power, lot, serial, sticker

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. Position and restas advised; avoid rubbing or pressing the eye
  2. Topical steroiddrug, frequency, planned taper; long-term in vascularised grafts
  3. Topical antibioticdrug, frequency, duration
  4. Antiviralif history of herpes simplex keratitis: drug, dose, duration
  5. IOPcheck on day 1 and at every visit
  6. Daily checksinfection, wound leak, loose sutures, epithelial defect, anterior synechiae, iritis, graft clarity
  7. Warning signs of rejection explainedredness, sensitivity to light, blurred vision, pain: come the same day
  8. Follow-upday 1, then as per cornea clinic schedule; suture removal only by the cornea team

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.K., 45 years, right eye dense central corneal scar 5 mm across after healed microbial keratitis 1 year ago, no active infection, no vessels in the central 8 mm. Vision counting fingers 1 m. Clear lens.

Case details

Date: 14/07/2026. Elective (donor tissue available). Eye OT 3.

Block 09:15. Incision 09:35. End 10:50.

Surgeon: Dr C. (consultant, cornea). Assistant and part of suturing: Dr A. (3rd-year resident). Scrub nurse: Sr E. Anaesthetist on standby: Dr D.

Indication and pre-op

Right eye: CF 1 m, projection accurate. Central stromal scar 5 x 4.5 mm, 80% depth. Periphery clear, no vessels. Clear lens. IOP 14 mmHg. B-scan: retina attached, vitreous clear.

Indication: optical penetrating keratoplasty. Lids normal, Schirmer's normal, corneal sensation present.

Donor: eye bank ID ________, donor 58 years, death-to-preservation 4 hours, stored in McCarey-Kaufman medium since 13/07/2026, endothelial cell count 2,650 cells/mm2, serology screen negative as per eye bank form.

Consent: general, procedure-specific and anaesthesia consent from the patient in Hindi, including rejection, long-term drops and need for glasses or contact lens.

Right eye marked. WHO checklist sign in and time out done. Pupil constricted with pilocarpine drops before surgery.

Anaesthesia and position

Peribulbar block, right eye, 7 ml of 2% lignocaine and 0.5% bupivacaine (2:1) with hyaluronidase 5 IU/ml and adrenaline 1:100,000. Compression 15 minutes, eye soft. Supine. Lids painted with povidone-iodine and draped. Wire speculum.

Procedure

Superior and inferior rectus traction sutures with silk 4-0.

Host cornea measured with calipers. Trephine size 7.5 mm chosen to include the whole scar.

Donor button punched from the endothelial side on the cutting block with a 7.75 mm trephine (0.25 mm larger than the host), covered with medium. Medium clear; sample sent for culture.

Paracentesis at 9 o'clock with a super-sharp blade. Visual axis marked with an inked Sinskey hook, radial marker applied for suture placement.

Hand-held 7.5 mm trephine, centred on the visual axis, cut to about 80% depth. AC entered with a super-sharp blade. Host button excised with right- and left-cutting corneal scissors, edge regular. Button sent for HPE.

Viscoelastic placed over iris and lens. Lens clear and untouched. No synechiae.

Donor button placed on the viscoelastic bed. Four cardinal interrupted nylon 10-0 sutures at 12, 6, 3 and 9 o'clock, even tension, diamond pattern seen.

Twelve further interrupted nylon 10-0 sutures placed, 16 in all. Knots buried.

Viscoelastic washed out with BSS through the paracentesis. AC formed, wound watertight.

Surgical keratometer: round mire. Traction sutures removed.

Closure

Subconjunctival antibiotic and steroid injected (drugs and doses as charted by Dr C.). Pad and shield.

Specimens and implants

Host button 7.5 mm in formalin for HPE, labelled, with requisition.

Donor medium sample sent for culture.

Eye bank donor label pasted in this note. No IOL.

End of procedure

Blood loss negligible. No complications.

Needle and instrument count correct.

Shifted to ward. Pulse 82/min, BP 128/80 mmHg.

Post-op orders

Do not rub or press the eye.

Pad off tomorrow morning. Examine graft, wound, AC and IOP.

Topical steroid and antibiotic drops as written on the drug chart by Dr C., with the taper plan.

Explained warning signs of rejection and infection: redness, light sensitivity, blurred vision, pain. Come to eye casualty the same day.

Follow up in cornea clinic as per schedule. Sutures to be removed only by the cornea team.

Signature

Dr A., JR-3, Ophthalmology, for Dr C. Reg. no. ________. 14/07/2026, 11:00.

Must document for this operation

  • Host and donor trephine sizes. Donor-host disparity affects refraction, and a regraft is planned from these numbers.
  • Donor details: eye bank ID, age, time from death to preservation, medium, endothelial count. If the graft fails early or an infection is traced to the donor, the eye bank needs the donor ID.
  • Number and type of sutures (interrupted, running, or both). Selective suture removal to reduce astigmatism depends on knowing the pattern.
  • Host button sent for HPE (and for culture when the graft is for infection), and donor medium sent for culture. An infection after the graft is treated on these results, and the HPE confirms the diagnosis.
  • Lens status and any intraocular work (iridectomy, vitrectomy, IOL). Tells the next surgeon what is behind the graft before any cataract or glaucoma surgery.
  • History of herpes simplex and whether antiviral cover was started. Recurrence of herpes in a graft without antiviral cover is a known cause of failure.

Common mistakes in these notes

  • Writing only 'PK done' without trephine sizes.
  • No donor ID or eye bank label in the note.
  • Not recording the number of sutures.
  • Not stating where the host button was sent, or that the donor medium went for culture.
  • Not recording the lens status at the end.

Indian practice and paperwork

  • 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. For a graft, the drop schedule and taper should be written. (NABH 5th ed., COP.14(e) and (f))
  • Consent must cover risks, benefits, alternatives and who will do the operation, in a language the patient understands. Write who operated if a resident sutured part of the graft. (NABH 5th ed., PRE.4(c))
  • The host button goes for HPE in formalin with a requisition. Discarded formalin is chemical waste in the yellow (f) category. (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 22, Penetrating Keratoplasty (Rauen M, Goins KM), pp. 205-230.
  • Roper-Hall MJ. Stallard's Eye Surgery. 7th ed. Wright (Butterworths); 1989, Ch 6, Corneal transplantation (keratoplasty), pp. 209-221.
  • Khurana AK, Khurana AK, Khurana B. Comprehensive Ophthalmology. 6th ed. Jaypee Brothers; 2015, Ch 6, Diseases of Cornea: keratoplasty, surgical technique of penetrating keratoplasty (donor button 0.25 mm larger than recipient), pp. 137.
  • Khurana AK, Khurana AK, Khurana B. Comprehensive Ophthalmology. 6th ed. Jaypee Brothers; 2015, Ch 26, Anaesthesia for ocular surgery (keratoplasty under local anaesthesia; peribulbar block), pp. 591-593.

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.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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