> ## Documentation Index
> Fetch the complete documentation index at: https://docs.bizaxl.com/llms.txt
> Use this file to discover all available pages before exploring further.
# Surgical Procedures
> How to record, manage, and track eye surgical procedures - from cataract surgery and YAG laser to intravitreal injections and minor lid surgeries.
Many eye care centers perform surgical and interventional procedures - from minor procedures done at the slit lamp (YAG laser, corneal foreign body removal) to major intraocular surgery (cataract surgery, retinal surgery). Each procedure has its own record, its own pre- and post-operative nursing checklists, and its own billing entry.
***
## Before You Start
* **Clinical Procedure Templates** must be set up for each type of surgery or procedure.
* Pre-operative nursing checklist templates should be configured.
* Post-operative nursing checklist templates should be configured.
* You need the **Healthcare Practitioner** role to order and record procedures.
* The **Nursing User** role is needed for pre-op and post-op checklists.
***
## Setting Up Surgical Procedure Templates (Admin Task)
Set up a template for each type of surgery or interventional procedure.
1. Go to Healthcare workspace → Consultation Setup card → **Clinical Procedure Template** → New
Recommended surgical templates for an eye care center:
| Template Name | Is Billable | Notes |
| ------------------------------------------------ | ----------- | ---------------------------------------------------- |
| Phacoemulsification (Cataract Surgery) | Yes | Standard cataract removal with IOL |
| Phaco + Foldable IOL (Premium) | Yes | For toric or multifocal IOL options |
| LASIK | Yes | Laser vision correction |
| PRK / LASEK | Yes | Surface laser correction |
| YAG Laser Capsulotomy | Yes | After cataract surgery for posterior capsule opacity |
| YAG Laser Peripheral Iridotomy | Yes | For narrow angle / angle-closure glaucoma |
| Selective Laser Trabeculoplasty (SLT) | Yes | Glaucoma laser treatment |
| Intravitreal Injection (Bevacizumab/Ranibizumab) | Yes | For wet AMD, diabetic macular oedema |
| Intravitreal Injection (Dexamethasone Implant) | Yes | For retinal vein occlusion, diabetic macular oedema |
| Chalazion Excision | Yes | Minor lid surgery |
| Epilation of Trichiatic Lashes | Yes | Misdirected lashes |
| Pterygium Excision | Yes | Conjunctival growth removal |
| Corneal Foreign Body Removal | Yes | Emergency/urgent procedure |
| Inferior Punctal Occlusion | Yes | For dry eye - punctal plug insertion |
| Trabeculectomy | Yes | Glaucoma filtering surgery |
| Vitrectomy (Pars Plana) | Yes | For retinal detachment, vitreous haemorrhage, ERM |
| Squint Surgery | Yes | Eye alignment correction |
| Ptosis Repair | Yes | Drooping eyelid correction |
For surgical templates, also configure:
* **Pre-op Nursing Checklist Template** (e.g., "Cataract Pre-op Checklist")
* **Post-op Nursing Checklist Template** (e.g., "Post-cataract Day 1 Checklist")
***
## Step 1: Surgical Decision Made in Eye Examination
When the doctor decides a patient needs surgery:
1. Open the Patient Encounter
2. In the **Clinical Procedures** section, add the procedure template
3. Add a note about the surgical plan (e.g., "Right eye phacoemulsification - IOL: +21.0D SN60WF, Surgeon: Dr. Kumar, Target: -0.25D")
4. Submit the encounter
A Clinical Procedure record is created for the surgical procedure.
***
## Step 2: Pre-Operative Assessment
Before surgery, a dedicated pre-op appointment is booked:
1. Book a **Pre-operative Assessment** appointment
2. The ophthalmic nurse/technician completes:
* Biometry (IOL power calculation) - via the Biometry Clinical Procedure
* Corneal topography
* Blood tests (blood sugar, CBC, ECG if required)
* Consent documentation (attach signed consent to the Clinical Procedure record)
* Blood pressure and systemic health check
3. Review Results: the surgeon reviews biometry results and confirms the IOL choice
***
## Step 3: Creating the Surgical Procedure Record
On the day of surgery (or when confirming the surgical plan):
1. Go to Healthcare workspace → Consultation card → **Clinical Procedure** → New (or open the auto-created record from the examination order)
2. Fill in the surgical details:
| Field | What to Enter |
| ----------------------- | ----------------------------------------------------------------------------------------- |
| Patient | The patient undergoing surgery |
| Procedure Template | The surgery type (e.g., Phacoemulsification) |
| Healthcare Practitioner | The operating surgeon |
| Medical Department | Ophthalmology / Surgery |
| Service Unit | Operating Theatre / Laser Room / Procedure Room |
| Start Date | Surgery date |
| Start Time | Scheduled start time |
| Notes | Surgical plan: IOL details, target refraction, anaesthesia type, any special instructions |
3. If surgery involves consumables (IOL, sutures, surgical kit), add them to the **Consumables** table
4. Save
***
## Step 4: Pre-operative Nursing Checklist
Before taking the patient into the operating room:
1. Open the Clinical Procedure record
2. The **Pre-op Nursing Checklist** section shows the standard checklist tasks
3. The nurse works through each item:
For cataract surgery, a typical pre-op checklist includes:
* Informed consent signed and filed
* Pupil dilation drops instilled (e.g., Tropicamide 1% + Phenylephrine 2.5% - given 3 times at 10-minute intervals)
* Surgical site marked (which eye)
* IV access established (if required)
* Preoperative antibiotic drops given (Povidone-Iodine 5%)
* Patient blood sugar checked (for diabetic patients)
* Pre-operative blood tests reviewed and cleared
* Anaesthesia type confirmed (topical, peribulbar, or general)
* Patient fasted (if general anaesthesia)
4. Set status to **In Progress** once the patient enters the surgical area
***
## Step 5: During the Procedure
1. The surgeon performs the procedure
2. After completion, add surgical notes to the Clinical Procedure record:
* IOL type and power implanted (for cataract surgery)
* Complications (if any)
* Intraoperative findings
* Drug injected (for intravitreal injections - drug name, lot number, dose)
* Laser parameters (for LASIK/laser procedures)
***
## Step 6: Post-operative Nursing Checklist and Recovery
1. Set status to **Completed** when the procedure is finished
2. The **Post-op Nursing Checklist** captures recovery tasks:
* Vision checked post-operatively
* Eye patch or shield applied
* Post-op drops prescribed and explained
* Post-op instructions given (no rubbing, no swimming, follow-up date)
* Patient observed in recovery area
3. When recovery is complete, submit the Clinical Procedure record
***
## Step 7: Surgical Procedure Submission
1. Click **Submit** on the Clinical Procedure record
Once submitted:
* The procedure appears in the patient's history
* It is available for billing
* The post-op follow-up appointment can be booked
***
## Post-operative Follow-up
After surgery, follow-up appointments are typically:
* Cataract surgery: Day 1, Week 1, Month 1 (and final prescription at 4-6 weeks)
* LASIK/PRK: Day 1, Week 1, Month 1, Month 3
* Intravitreal injection: 4-6 weeks (per treatment protocol)
* YAG laser: 2-4 weeks
Book these follow-up appointments immediately after the procedure so the patient leaves with their dates confirmed.
***
## Field Guide: Clinical Procedure (Surgical)
| Field | What It Contains |
| ----------------------- | ----------------------------------------------- |
| Patient | The patient |
| Procedure Template | Type of surgery or procedure |
| Healthcare Practitioner | The operating surgeon |
| Service Unit | Operating room or laser room |
| Start Date / Time | When the procedure was performed |
| Status | Draft, In Progress, Completed, Submitted |
| Notes | Surgical notes, IOL details, drug details |
| Items (Consumables) | Surgical consumables used (IOL, sutures, drugs) |
| Invoiced | Whether the surgical fee has been billed |
***
## Billing for Surgical Procedures
Each surgical procedure has an Invoiced field. The procedure fee and consumable costs can be billed:
* As a single bundled surgical fee
* As procedure fee + consumables separately (if "Invoice Separately as Consumables" is configured)
For cataract surgery, a typical invoice includes:
* Surgeon fee
* Anaesthesia fee
* OT facility charge
* IOL cost (if not bundled into the surgical fee)
* Pre-operative investigation fees
* Post-operative follow-up fees
See [Billing and Finance](/health-wellness/eye-care-center/billing-finance) for the full process.
***
## Troubleshooting
**The pre-op checklist is not appearing in the Clinical Procedure record**
A pre-op nursing checklist template must be linked to the Clinical Procedure Template. Open the template and add the Nursing Checklist Template in the Pre-op Checklist Template field.
**The IOL or surgical consumable is not appearing in the consumables table**
The item must exist in the inventory/items master. Ask your administrator to add the IOL brand and model as an item.
**A patient is booked for surgery but the Clinical Procedure record shows no biometry result**
Biometry must be completed before surgery confirmation. Check the Biometry Clinical Procedure record for this patient and ensure it has been submitted with the IOL calculation results.
***
## Best Practices
* Always complete biometry and confirm the IOL choice at least one week before surgery - last-minute IOL changes can lead to wrong lenses being ordered
* For intravitreal injections, record the drug lot number and expiry date in the Notes field - this is needed for traceability in case of any adverse events
* Attach the signed consent form to the Clinical Procedure record before the procedure starts - starting surgery without documented consent is a medico-legal risk
* Post-op drops should be prescribed in the encounter at the time of surgery and a printed copy given to the patient before they leave - do not rely on the patient to remember verbal instructions
* Book all post-op follow-up appointments before the patient leaves the clinic on surgery day - patients who leave without a follow-up booking often do not return
***
## Related Features
* [Eye Examination](/health-wellness/eye-care-center/eye-examination): Surgical decisions are made in the examination record
* [Clinical Investigations](/health-wellness/eye-care-center/clinical-investigations): Biometry and corneal topography for surgical planning
* [Inpatient Management](/health-wellness/eye-care-center/inpatient-management): For patients admitted to a day surgery bay or overnight
* [Billing and Finance](/health-wellness/eye-care-center/billing-finance): Surgical procedures and consumables billing