- Abnormalities of the Pupil
- Atopic Keratoconjunctivitis (AKC)
- Basal cell carcinoma (BCC) (periocular)
- Blepharitis (Lid Margin Disease)
- CL-associated Papillary Conjunctivitis (CLAPC), Giant Papillary Conjunctivitis (GPC)
- Cellulitis, preseptal and orbital
- Chalazion (Meibomian cyst)
- Concretions
- Conjunctival pigmented lesions
- Conjunctival scarring
- Conjunctivitis (Acute Allergic)
- Conjunctivitis (bacterial)
- Conjunctivitis (viral, non-herpetic)
- Conjunctivitis (seasonal & perennial allergic)
- Conjunctivitis, Chlamydial
- Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa)
- Corneal (or other superficial ocular) foreign body
- Corneal Transplant Rejection
- Corneal abrasion
- Corneal hydrops
- Dacryocystitis (acute)
- Dacryocystitis (chronic)
- Dry Eye (Keratoconjunctivitis Sicca, KCS)
- Ectropion
- Endophthalmitis (post-operative) (Exogenous endophthalmitis)
- Entropion
- Episcleritis
- Facial palsy (Bell's Palsy)
- Fuchs Endothelial Corneal Dystrophy (FECD)
- Glaucoma (chronic open angle) (COAG)
- Herpes Simplex Keratitis (HSK)
- Herpes Zoster Ophthalmicus (HZO)
- Hordeolum
- Keratitis (marginal)
- Keratitis, CL-associated infiltrative
- Microbial keratitis (Acanthamoeba sp.)
- Microbial keratitis (bacterial, fungal)
- Molluscum contagiosum
- Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
- Ocular hypertension (OHT)
- Ocular rosacea
- Ophthalmia neonatorum
- Photokeratitis (Ultraviolet [UV] burn, Arc eye, Snow Blindness)
- Phthiriasis (pediculosis ciliaris)
- Pigmented fundus lesions
- Pinguecula
- Post-operative suture breakage
- Primary Angle Closure / Primary Angle Closure Glaucoma (PAC / PACG)
- Pterygium
- Recurrent corneal epithelial erosion syndrome
- Retinal Vein Occlusion
- Scleritis
- Steroid-related Ocular Hypertension and Glaucoma
- Sub-conjunctival haemorrhage
- Sub-tarsal foreign body (STFB)
- Trauma (blunt)
- Trauma (chemical)
- Trauma (penetrating)
- Trichiasis
- Uveitis (anterior)
- Vernal Keratoconjunctivitis
- Vitreomacular Traction and Macular Hole
- How to use the Clinical Management Guidelines
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])
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
© College of Optometrists
- Abnormalities of the Pupil
- Atopic Keratoconjunctivitis (AKC)
- Basal cell carcinoma (BCC) (periocular)
- Blepharitis (Lid Margin Disease)
- CL-associated Papillary Conjunctivitis (CLAPC), Giant Papillary Conjunctivitis (GPC)
- Cellulitis, preseptal and orbital
- Chalazion (Meibomian cyst)
- Concretions
- Conjunctival pigmented lesions
- Conjunctival scarring
- Conjunctivitis (Acute Allergic)
- Conjunctivitis (bacterial)
- Conjunctivitis (viral, non-herpetic)
- Conjunctivitis (seasonal & perennial allergic)
- Conjunctivitis, Chlamydial
- Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa)
- Corneal (or other superficial ocular) foreign body
- Corneal Transplant Rejection
- Corneal abrasion
- Corneal hydrops
- Dacryocystitis (acute)
- Dacryocystitis (chronic)
- Dry Eye (Keratoconjunctivitis Sicca, KCS)
- Ectropion
- Endophthalmitis (post-operative) (Exogenous endophthalmitis)
- Entropion
- Episcleritis
- Facial palsy (Bell's Palsy)
- Fuchs Endothelial Corneal Dystrophy (FECD)
- Glaucoma (chronic open angle) (COAG)
- Herpes Simplex Keratitis (HSK)
- Herpes Zoster Ophthalmicus (HZO)
- Hordeolum
- Keratitis (marginal)
- Keratitis, CL-associated infiltrative
- Microbial keratitis (Acanthamoeba sp.)
- Microbial keratitis (bacterial, fungal)
- Molluscum contagiosum
- Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
- Ocular hypertension (OHT)
- Ocular rosacea
- Ophthalmia neonatorum
- Photokeratitis (Ultraviolet [UV] burn, Arc eye, Snow Blindness)
- Phthiriasis (pediculosis ciliaris)
- Pigmented fundus lesions
- Pinguecula
- Post-operative suture breakage
- Primary Angle Closure / Primary Angle Closure Glaucoma (PAC / PACG)
- Pterygium
- Recurrent corneal epithelial erosion syndrome
- Retinal Vein Occlusion
- Scleritis
- Steroid-related Ocular Hypertension and Glaucoma
- Sub-conjunctival haemorrhage
- Sub-tarsal foreign body (STFB)
- Trauma (blunt)
- Trauma (chemical)
- Trauma (penetrating)
- Trichiasis
- Uveitis (anterior)
- Vernal Keratoconjunctivitis
- Vitreomacular Traction and Macular Hole
- How to use the Clinical Management Guidelines
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