Pterygium excision with conjunctival autograft

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

• recurrence of the pterygium
• graft swelling, graft slipping or loss
• graft or corneal infection
• corneal scar or opacity that remains after removal
• damage to the medial rectus with double vision (rare)
• scleral thinning or necrosis (rare)
• cyst or granuloma at the graft site
• change in spectacle power as astigmatism settles

Pre-operative details for this operation

1. Eye and side of pterygiumRE nasalRE temporalLE nasalLE temporaleye marked above the eyebrow
2. Primary or recurrentif recurrent: number of previous operations and technique
3. Indicationencroachment in mm across the limbus, documented growth, induced astigmatism, irritation, restricted eye movement, suspicious appearance (CIN), cosmesis
4. Vision and keratometry / topographybaseline astigmatism; note if cataract surgery is planned later
5. Eye movementsfull / restricted abduction

Anaesthesia and position

1. AnaesthesiaPeribulbar blockSub-Tenon blockTopicaldrug, strength, volume, who gave it
2. Preparationantiseptic and strength; lashes isolated; speculum

Operative findings

1. Pterygium sizeextent onto cornea from limbus in mm, width at limbus, fleshy / atrophic
2. Tenon's tissueamount; extent towards caruncle
3. Corneal bed after removalsmooth / residual opacity / thinning
4. Medial (or lateral) rectusidentified and protected; insertion intact
5. Scleranormal / thin

Procedure (steps)

1. Limbus marked and pterygium transected at the limbus
2. Head removed from corneaStripped with forcepsDissected with blade
3. Conjunctiva separated from Tenon'sextent of dissection towards the semilunar fold, above and below the rectus
4. Tenon's excisedhow far back (e.g. to caruncle); rectus retracted with a squint hook; sclera checked clear
5. Conjunctival edges and semilunar foldfree edge marked; amount excised; semilunar fold removed or not
6. HaemostasisWet-field cauteryPressure only
7. Corneal and limbal bed smoothedDiamond burrBladeNot needed
8. Graft marked and harvesteddonor site (usually superior bulbar), size in mm, 1 to 2 mm limbal conjunctiva left at the donor site, Tenon's not taken, orientation mark
9. Graft placed in the correct orientationlimbal edge to limbus, epithelial side up
10. Graft fixationSuturesFibrin gluesuture material and size, number and position of sutures (limbal edge, posterior corners, sides)
11. AdjuvantNoneOther (drug, strength, time)

Closure, drains and dressing

1. Donor siteLeft bareClosed (suture)
2. Semilunar fold reconstructedYes, graft to caruncular edgeNot done
3. Drops / ointment at enddrug
4. PadPadPressure patch (after block)Bandage contact lens

Specimens and implants

1. Pterygium tissueSent for HPEDiscardedsend if appearance suggests CIN or it is recurrent; label with eye and side
2. Fibrin glue (if used)make, batch number

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. Padtill next-day review; do not rub the eye
2. First reviewgraft in place and oriented, graft colour and swelling, sutures, corneal bed epithelium
3. Eye dropssteroid and antibiotic drops: drug, frequency, taper as per unit regimen
4. Suturesnote whether sutures need removal and when
5. Warning signspain, discharge, drop in vision, graft seen missing: come back the same day
6. Recurrence checkfollow-up visits for regrowth at the limbus
7. Before cataract surgeryrepeat keratometry / biometry after 1 to 3 months once the cornea has settled

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