Plaque radiotherapy
1. Surgeon informs patient of all relevant aspects of treatment.
2. Junior doctor obtains consent for plaque insertion and removal.
3. Surgeon inserts plaque, computerizes data, writes operation notes, completes yellow form.
4. Surgeon completes dosimetry request form and gives form to theatre staff.
5. Theatre Nurse faxes form to CCO within an hour of surgery.
6. Oncology Secretary receives dosimetry report and gives to consultant.
7. Consultant checks and signs form, confirming time of removal of plaque.
8. Oncology secretary informs theatre and ward of plaque removal time.
9. Junior doctor organises plaque removal, (1) informing patient of time of plaque removal, (2) recruiting anaesthetist, surgeon and ODA, and (3) confirming operating slot with theatre staff.
10. Surgeon removes plaque, ensuring that the under side of the plaque is not touched and that cautery is not used.

Plaque removal
1. Remove conjunctival sutures.
2. Retract conjunctiva with Fison's retractor. After local resection, do not simultaneously exert traction on eyeball as this may cause dehiscence of the scleral wound.
3. Do not apply cautery as bleeding is usually diffuse and stops after irrigation with cold saline.
4. Detach disinserted muscle from mattress suture or lugs or sclera.
5. Do not remove old sutures from belly of muscle as these hold muscle fibres together.
6. Remove mattress suture.
7. Cut lug sutures and remove.
8. Lift plaque from eye without touching under-surface and without pointing plaque towards anybody.
9. Swab away any blood clots.
10. Suture dis-inserted rectus muscle to tendon (not sclera) ensuring that knots in muscle belly are at same distance from limbus as before dis-insertion. Refer to original operation notes for this information.
11. Do not re-insert oblique muscles as these should be held in correct anatomical position by adhesions to Tenon's capsule.
12. Suture conjunctiva in usual fashion.
13. Administer standard antibiotic and mydriatic drops.
14. Discharge patient on topical antibiotics (for one week), steroids (for four weeks), and mydriatics (for one week).

Conjunctival biopsy
1. Anaesthetise the conjunctiva with topical Benoxinate drops and small amounts of subconjunctival lignocaine with adrenaline.
2. Grasp the conjunctiva with toothed microforceps. Do not grasp the conjunctiva in more than one place.
3. Excise an ellipse of conjunctiva, approximately 5 mm by 3 mm in size, using fine Vannas scissors.
4. Gently place the biopsy on a card and immerse in fixative. Do not forcibly flatten specimen on paper as this will cause cruch artifact
5. Leave conjunctiva unsutured.
6. Write prescription for topical antibiotic drops for three or four days.
7. Complete pathology form.

Trans-pupillary thermotherapy
1. Anaesthetise patient with retrobulbar injection. If possible, inject about 2 ml of Marcaine/Lignocaine just behind the globe in the muscle cone, so as to preserve ocular movements.
2. Set beam width to 3 mm. Adjust delivery system so that this is located at centre of slit. Reduce power of slit illumination.
3. Apply one minute applications to entire tumour surface and a surround of 1.5-2.0 mm. Adjust the laser intensity so that (1) the retinal vasculature is not obliterated, and (2) retinal blanching develops after approximately 45 seconds. Start at approximately 450 mW and increase power at 50 mW intervals.

Enucleation Procedure and Post Operative Care
1. Give 5-8 ml of retrobulbar injection of Marcaine 0.75% with 1:100,000 adrenaline when patient is asleep.
2. After draping the patient, perform indirect ophthalmoscopy to see the tumour and ensure that you are operating on the correct eye.
3. Perform conjunctival peritomy.
4. Disinsert six extraocular muscles, placing 5-0 vicryl sutures onto recti.
5. Suture inferior oblique to belly of lateral rectus, about 5mm from insertion.
6. Leave medial rectus stump long enough to grasp with artery forceps.
7. Open speculum as much as possible. Clamp optic nerve with artery forceps as far posteriorly as possible. Cut optic nerve with enucleation scissors, holding scissors parallel to medial wall of orbit.
8. Measure orbital volume with ball.
9. Introduce HA ball in vicryl mesh, using cut thumb of disposable glove as a slide.
10. Pull Tenon's capsule anteriorly with two pairs of toothed forceps so that Tenon's capsule prolapses anterior to ball.
11. Remove slide.
12. Place a 4-0 vicryl suture through vicryl mesh on anterior surface of ball implant, to act as a marker.
13. Suture rectus muscles to ball about 8mm from centre, with superior rectus about 11mm from centre.
14. Suture Tenon's capsule with continuous 4-0 vicryl suture, avoiding gaps and being careful not to pass suture through conjunctiva or levator muscle. Maintain superior fornix with squint hook.
15. Close conjunctiva with continuous 8-0 vicryl suture and instill antibiotic drops.
16. Insert conformer of appropriate size.
17. Place triple pad and bandage on eye.
18. Prescribe Brufen and oral antibiotics for one week.
19. Remove pad and discharge patient two days after surgery.
20. Before the patient leaves the hospital, ensure that Ocular Oncology Nurse has completed a referral for to the National Artificial Eye Service and that the District Nurse has been asked to attend the patient at home to clean the socket and instil antibiotics.

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