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)

• 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 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

Caution should be exercised if it is planned to remove a loose or broken corneal transplant or trabeculectomy 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)

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

A3: urgent (within one week) referral to ophthalmologist

A1: emergency (same day) referral to ophthalmologist if:

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

B2 (modified): suture removal, preferably following discussion with the HES

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

None applicable

Post-operative suture breakage
Version 12
Date of search 10.12.20
Date of revision 25.02.21
Date of publication 20.08.21
Date for review 09.12.22
© College of Optometrists