OT notes · Ophthalmology

Probing for congenital nasolacrimal duct obstruction

Usual anaesthesia
General anaesthesia (office probing under topical anaesthesia in infants 6 to 9 months is done by some)
Position
Supine
Setting
elective

Operative note template for probing (with or without irrigation, turbinate medialisation or silicone intubation) for congenital nasolacrimal duct obstruction, with a filled example for a first probing and irrigation under general anaesthesia in a 14-month-old child.

Download printable PDFFree. Just log in with your Google (Gmail) account.

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 may continue and a repeat probing may be needed
  • false passage or injury to the canaliculus
  • nose bleed
  • injury to the inferior turbinate or floor of the nose
  • need for silicone tube, balloon dilation or later DCR if probing fails
  • tube problems if a tube is placed: slipping, splitting of the punctum, corneal abrasion, granuloma
  • risks of general anaesthesia

Pre-operative details for this operation

  1. Agemonths; probing is usually advised after sac compression fails, often around 12 months
  2. SideRightLeftBoth
  3. Symptoms sincewatering, discharge, matted lashes; onset (usually first month)
  4. Signstear meniscus, regurgitation on pressure over sac (ROPLAS), fluorescein dye disappearance test (FDDT)
  5. Sac compression donehow long; taught to parents
  6. Previous probingNoneOnce (date)More than once
  7. Special featuresNoneDacryoceleLacrimal fistulaSyndrome / craniofacial anomalyPunctal atresia
  8. Fasting and fitness for GApaediatric / anaesthesia check

Anaesthesia and position

  1. AnaesthesiaGeneralTopical with restraint (office)
  2. PositionSupine
  3. Nasal decongestionoxymetazoline (strength) on cotton pledgets under and medial to the inferior turbinate
  4. VisualisationLoupes and headlightNasal endoscope

Operative findings

  1. PunctaNormalStenosedAtretic
  2. Irrigation before probingComplete reflux (block confirmed)Partial passageFree passage
  3. Canalicular passageSmoothSoft stop / canalicular fold
  4. Hard stop reachedYes
  5. ObstructionSimple: membranous give at lower endComplex: firm / bony / buried probe / no duct
  6. Probe in inferior meatusConfirmed (metal-to-metal / seen on endoscopy)Not confirmed
  7. Irrigation after probingFluorescein recovered from nose, no refluxReflux persists
  8. Nasal findingsturbinate position, intranasal cyst, false passage

Procedure (steps)

  1. Nasal pledgets placedoxymetazoline; one under and one medial to the inferior turbinate
  2. Upper punctum dilatedNettleship dilator
  3. Pre-probing irrigationfluorescein-stained saline through the upper punctum
  4. Probe sizeBowman number (e.g. 00 neonate, 0 infant, 1 for 1-4 years); probe lubricated
  5. Canalicular passagevertical 2 mm, then horizontal with the lid stretched laterally, towards the medial canthus; no force at a fold
  6. Hard stop at medial wall of sacthen withdrawn 1 mm
  7. Probe rotated and advanced down the ductturned 90 degrees, flat against brow in line with trochlea, slightly temporal; directed down, back and out
  8. Obstruction overcomegive felt; probe advanced only a few mm more
  9. Probe position confirmedmetal-to-metal touch with a spatula in the inferior meatus, or seen on endoscopy
  10. Inferior turbinate medialisationNot doneDone (Freer elevator, reason)
  11. Post-probing irrigationfluorescein recovered from the nose by suction
  12. Silicone intubation (if failed probing or complex block)Not doneBicanalicular (Crawford)Monocanalicular (Mini-Monoka)retrieved under inferior turbinate; how secured (silicone block / knot); left loose

Closure, drains and dressing

  1. Nasal pledgets removedYes, count correct
  2. Nasal bleeding at endNoneMinimal, settled with pressure
  3. Eye at endcornea clear, tube loop position if placed

Specimens and implants

  1. Silicone stent (if placed)type, make, lot number, sticker
  2. SpecimenNone

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. Recoveryas per paediatric anaesthesia orders; feeds when awake
  2. Topical antibioticonly if discharge or infection: drug, frequency, duration
  3. Watch fornose bleed more than blood-tinged tears, fever, swelling at the inner corner
  4. Tube care (if placed)parents told to report a visible loop or tube in the eye
  5. Reviewabout 4 to 6 weeks; FDDT and symptoms
  6. If watering persistsrepeat probing, balloon dilation or silicone intubation
  7. Tube removal (if placed)planned date; timing varies: about 6 months (Albert atlas, Khurana), PEDIG 2 to 5 months, success reported with removal at 6 weeks and at 6 months or later (Ali, Lacrimal Surgery)

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: Baby A.S., 14 months, male, with watering and sticky discharge from the right eye since the first month of life, not better after 6 months of sac compression taught to the mother.

Case details

Date: 22/09/2026. Elective, paediatric list. OT 3. Induction 09:05. Start 09:15. End 09:30.

Surgeon: Dr A. (1st-year resident, Ophthalmology). Consultant: Dr C., present and scrubbed.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: right congenital nasolacrimal duct obstruction. Watering and discharge since the first month. Raised tear meniscus, regurgitation of mucus on pressure over the right sac, FDDT delayed on the right. Left eye normal. No dacryocele, no fistula, no syndrome.

Sac compression four sessions a day for 6 months, no improvement. First probing.

Weight 9.6 kg. Paediatric and anaesthesia check done. Fasting as per anaesthesia instructions.

Consent: procedure-specific and anaesthesia consent from the mother in Hindi, including that a repeat probing or tube may be needed.

Right eye marked. WHO checklist done. No systemic antibiotic.

Anaesthesia and position

General anaesthesia. Supine. Right nose packed with cotton pledgets soaked in oxymetazoline 0.025%, one under and one medial to the inferior turbinate. Loupes and headlight.

Procedure

Right upper punctum normal, dilated with a Nettleship dilator.

Fluorescein-stained saline injected through the upper punctum: complete reflux, block confirmed.

No. 1 Bowman probe, lubricated with ointment, passed vertically into the upper punctum, then horizontally with the upper lid stretched outwards, until a hard stop was felt at the medial wall of the sac.

Probe withdrawn 1 mm, turned 90 degrees to lie flat against the brow in line with the trochlea, and passed gently down, back and slightly out along the nasolacrimal duct.

Membranous resistance at the lower end gave way with gentle pressure. Probe advanced only a few mm further.

Probe position confirmed by metal-to-metal touch with a spatula placed in the inferior meatus. Turbinate medialisation not needed.

Repeat irrigation with fluorescein-stained saline: no reflux, dye recovered from the right nose on suction.

Findings

Simple membranous obstruction at the lower end of the right nasolacrimal duct. Canaliculi normal. No false passage. No intranasal cyst seen.

Closure

Both nasal pledgets removed, count correct. Slight blood-tinged fluid from the nose, settled. Cornea clear.

End of procedure

No implant. No specimen. Blood loss negligible.

No intra-operative complications. Child woke up well, shifted to paediatric recovery. Heart rate 118/min, SpO2 99% on air.

Post-op orders

Feeds when fully awake, as per anaesthesia orders.

Topical antibiotic drops to the right eye for 1 week as charted, because of discharge before surgery.

Mother told that blood-tinged tears for a day are expected. Return if heavy nose bleed, fever or swelling at the inner corner.

Review in the paediatric ophthalmology OPD at 6 weeks with FDDT. If watering persists, plan repeat probing with silicone intubation.

Signature

Dr A., JR-1, Ophthalmology. Reg. no. ________. 22/09/2026, 09:45.

Must document for this operation

  • Age, duration of symptoms and conservative treatment tried. Most cases resolve by 1 year, so the note must show why probing was done at this age.
  • Punctum used, probe size and the course of the probe. If the probing fails, the next surgeon needs to know what size passed and where resistance was felt.
  • Type of obstruction found (simple membrane or complex). Complex blocks fail more often and change the next step to intubation or balloon dilation.
  • How the probe position in the nose was confirmed. An unconfirmed probe may be in a false passage, which explains a failed result.
  • Irrigation result before and after probing. This is the only on-table proof that the duct was opened.
  • Stent details and removal plan, if a tube was placed. Tubes left too long or forgotten cause punctal damage and granulomas.

Common mistakes in these notes

  • Writing 'probing done, patent' without the probe size or how patency was confirmed.
  • Not recording which punctum was used.
  • Not recording the side, especially when both sides are listed but only one is probed.
  • No follow-up date or plan if watering continues.
  • Not noting a dacryocele, fistula or syndrome that changes the prognosis.

Indian practice and paperwork

  • Consent must explain the procedure, risks, alternatives and who will do it, in a language the parent understands, and be taken by the person doing the procedure. (NABH 5th ed., PRE.4(c) and (e))
  • 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. (NABH 5th ed., COP.14(e) and (f))
  • If a silicone stent is placed, record its batch and serial number in the case record, the OT logbook and the discharge summary. (NABH 5th ed., MOM.10(d))
  • Paediatric case records can be kept until the child reaches majority, as advised in Indian medicolegal guidance. (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 93, Lacrimal Probing and Intubation (Devoto MH), pp. 977-985.
  • Ali MJ, ed. Principles and Practice of Lacrimal Surgery. Springer India; 2015, Ch 12, Congenital Nasolacrimal Duct Obstruction (Kamal S, Ali MJ, Gauba V, Qasem Q), pp. 117-131.
  • Khurana AK, Khurana AK, Khurana B. Comprehensive Ophthalmology. 6th ed. Jaypee Brothers; 2015, Ch 16, Diseases of Lacrimal Apparatus: congenital dacryocystitis, treatment, pp. 393.

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.

This page cannot be printed from the browser. Use the Download printable PDF button on the page.