Post-operative suture breakage

Contents

Aetiology

Breakage of a suture or sutures remaining after surgery, usually with protrusion of broken end or knot

Predisposing factors

Corneal transplant sutures (usually 10/0 monofilament nylon or polyester fibre (Prolene)

  • continuous suture: single suture sewn in zigzag pattern alternately between the transplant and host. Usually left in situ for a year or more
  • interrupted sutures: usually 16 (range 8-24) sutures. Individual interrupted sutures, or diametrically opposite pairs of sutures, are sometimes removed earlier for control of astigmatism. Most usually left in situ for a year or more

Sutures used in other surgery (usually either nylon or polygalactin Vicryl)

  • cataract, glaucoma, pterygium, squint, vitreoretinal procedures

Even if their material is inert, all sutures can cause irritation when loose or broken and this can predispose to inflammation and infection

Symptoms of post-operative suture breakage

One or more of the following may be present:

  • foreign body sensation
  • irritation
  • redness
  • photophobia
  • epiphora
  • alteration in visual acuity following changes in astigmatism

Signs of post-operative suture breakage

One or more of the following may be present:

  • suture end may be visible
  • discharge – may be purulent, if infected
  • injection ± corneal vascularisation (enhanced risk of transplant rejection)
  • corneal infiltrate around suture ± corneal abscess ± hypopyon
  • uveitis: flare, cells and KPs. Intraocular pressure may be raised
  • mucus filaments
  • conjunctival hyperaemia
  • papillae on overlying tarsal conjunctiva (more common in chronic irritation)
  • wound leak (Seidel positive if fluorescein pool [2% Minims] appears diluted as aqueous oozes from site of leak [use cobalt blue filter])

Differential diagnosis

Foreign body (corneal or sub-tarsal)

Allergic conjunctivitis

Idiopathic acute anterior uveitis

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

Non pharmacological

Caution should be exercised if it is planned to remove a loose or broken suture

Sterile instruments must be used, e.g. sterile suture removal forceps, disposable blade or cutter

The wound should be checked for leakage after suture removal, using the Seidel test

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Pharmacological

Topical anaesthetic (gutt. proxymetacaine 0.5% or gutt. oxybuprocaine 0.4%) may be necessary to aid examination and for suture removal

Topical lubricant (gel-based or ointment) for symptomatic relief

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

If there is a likelihood of infection, consider topical antibiotic prophylaxis (e.g. gutt. chloramphenicol 0.5%)

(GRADE*: Level of evidence=low, Strength of recommendation=weak) 

Management category

A1: emergency (same day) referral to ophthalmologist if any of the following: 

  • recent surgery 
  • evidence of infection / inflammation 
  • wound leak present 
  • broken corneal transplant suture (risk of rejection)

A3: urgent (within one week) referral to ophthalmologist

B2 (modified): suture removal, following discussion with the surgeon/HES provider

Possible management by ophthalmologist

Removal of offending suture, followed by topical antibiotic ± steroid

Possibly send for microbiology/histology

Anterior chamber tap/vitreous tap if required

Re-suturing if necessary

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup.org)

Sources of evidence

Christo CG, van Rooij J, Geerards AJ, Remeijer L, Beekhuis WH. Suture-related complications following keratoplasty: a 5-year retrospective study. Cornea. 2001;20(8):816-9. https://pubmed.ncbi.nlm.nih.gov/11685058/ 

Nirankari VS, Karesh JW, Richards RD. Complications of exposed monofilament sutures. Am J Ophthalmol. 1983;95(4):515-9.

Shahinian L Jr, Brown SI. Postoperative complications with protruding monofilament nylon sutures. Am J Ophthalmol. 1977;83(4):546-8.

Siganos CS, Solomon A, Frucht-Pery J. Microbial findings in suture erosion after penetrating keratoplasty. Ophthalmology. 1997;104(3):513-6.

Summary

What is Post-operative Suture Breakage?

It sometimes happens that, following surgery to the eye, a suture (stitch) breaks. If this happens, the eye can become uncomfortable and it may feel as if there is a piece of grit in the eye. The eye may also water excessively, become red, unduly sensitive to light and sometimes the vision is affected. 

How is Post-operative Suture Breakage managed?

Depending on the severity of the case, the optometrist will usually refer either the patient either urgently or as an emergency to the ophthalmologist, who will trim or remove the broken suture(s) or resuture if necessary.

Post-operative suture breakage
Version 13
Date of search 23.01.23
Date of revision 23.03.23
Date of publication 26.05.23
Date for review 22.01.25
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