Post-operative suture breakage

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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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

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

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

GRADE Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Non pharmacological

None

Pharmacological
  • Topical anaesthetic (gutt. proxymetacaine 0.5% or gutt. oxybuprocaine 0.4%) may be necessary to aid examination
  • Topical lubricant (gel-based or ointment) for symptomatic relief

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

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 following consultation with on-call ophthalmologist

Possible management by ophthalmologist

  • Removal of offending suture. Possibly send for microbiology/histology.
  • Topical antibiotic ± steroid 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

Lay summary

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 and be unduly sensitive to light. Sometimes the vision is affected. Depending on the severity of the case, the optometrist will refer either urgently or as an emergency to the ophthalmologist, who will usually trim or remove the broken suture(s).

Post-operative suture breakage
Version 10
Date of search 19.09.16
Date of revision 22.12.16
Date of publication 01.06.17
Date for review 18.09.18
© College of Optometrists

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