Suture-related corneal infectionsafter clear corneal cataract surgery

Brian J. Lee, MD, Scott D. Smith, MD, MPH, Bennie H. Jeng, MD

Three patients at our institution developed corneal infections associated with sutures placed afterclear corneal incision cataract surgery. The time to infection was 9 weeks, 22 months, and 33months. One patient required injection of intravitreal antibiotic agents for presumed endophthal-mitis associated with the corneal infection. Two patients were treated with topical fortified antibi-otic eyedrops only. Although there was no significant change in visual acuity after resolution of theinfection, morbidity from suture-related corneal infections can be significant. Routine sutureremoval in the early postoperative period may be warranted to prevent such infections.

J Cataract Refract Surg 2009; 35:939–942 Q 2009 ASCRS and ESCRS

CASE REPORT

Phacoemulsification with posterior chamber intraocu-lar lens (PC IOL) implantation through a clear cornealincision has become the preferred method for cataractextraction. A 2003 survey of ophthalmologists in theUnited States showed that 72% of respondents usedclear corneal incisions, and of those surgeons, 92%used a no-suture technique.1 However, given thatover 2.5 million cataract surgeries are performed inthe U.S. each year, there are many cases in which10-0 nylon sutures are used to close the cornealwound.1

Previously described suture-related complicationsinclude epithelial erosions, corneal ulcers, cornealabscesses, and endophthalmitis.2–7 However, thisinformation is derived primarily from the corneal

Submitted: October 1, 2008.Final revision submitted: October 25, 2008.Accepted: October 26, 2008.

From the Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, USA.

No author has a financial or proprietary interest in any material ormethod mentioned.

Presented in part at the annual meeting of the American Academy ofOphthalmology, New Orleans, Louisiana, USA, November 2007.

Supported in part by a Research to Prevent Blindness ChallengeGrant, Department of Ophthalmology, Cleveland Clinic LernerCollege of Medicine (S.D.S. and B.H.J.), and NIH 1KL2 RR024990Multidisciplinary Clinical Research Training Award (B.H.J.)

Corresponding author: Bennie H. Jeng, MD, Department of Oph-thalmology, University of California, San Francisco, 10 KoretWay, K-304, San Francisco, California 94143, USA. E-mail:jengb@vision.ucsf.edu.

Q 2009 ASCRS and ESCRS

Published by Elsevier Inc.

transplantation literature. After penetrating kerato-plasty (PKP), general guidelines for suture removalhave emerged: sutures are typically removed 12 to18 months postoperatively unless they are loose orany sign of infection is seen.2,4

To our knowledge, no study has reported corneal in-fectious complications associated with corneal suturesplaced during clear corneal cataract surgery. It isknown that over time, nylon sutures placed duringcataract surgery degrade. Three years after cataractsurgery, 88% to 90% of sutures are broken or loose.8,9

When loose or broken sutures are removed after cata-ract surgery, about 40% will demonstrate bacterialcontamination.10 The potential morbidity associatedwith suture-related infections is illustrated by a caseseries of 4 patients who developed endophthalmitisafter extracapsular cataract extractionwith PC IOL im-plantation.11 We report 3 patients who developed cor-neal infectious complications due to loose or brokencorneal sutures after clear corneal cataract surgery.

CASE REPORTS

Case 1

A 75-year-old woman had uneventful phacoemulsifica-tion with PC IOL implantation through a temporal clearcorneal incision in the left eye. The postoperative best spec-tacle-corrected visual acuity (BSCVA) was 20/20. Twenty-two months later, the patient presented with complaints of‘‘irritation’’ and ‘‘a bloodshot left eye,’’ with pinhole visualacuity of 20/30. A loose suture at the site of the clear cornealtemporal incision was identified on slitlamp examination,but no corneal infiltrate was seen. The suture was removedand the patient treated with B–trimethoprim eyedrops 4times daily. On follow-up 3 days later, the visual acuityhad decreased to counting fingers and a dense infiltratehad developed at the prior suture site along with a 1.0 mm

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940 CASE REPORT: SUTURE-RELATED CORNEAL INFECTIONS

Table 1. Clinical data of 3 cases of corneal infection.

Age (Y)/ Sex ProcedureTime fromSurgery Complication Status of Suture

OrganismCultured

Change inBSCVA

75/F Phaco/IOL OS 22 months Suture ulcerwith

endophthalmitis

Loose suture Undetermined Unchanged

78/M Phaco/IOL/ trabwith MMC OS

33 months Suture abscess Broken suture MRSA 1 line loss

28/M IOFB removalwith phaco/IOL

OD

9 weeks Suture abscess Loose suture P acnes 2 line gain

BSCVA Z best spectacle-corrected visual acuity; IOFB Z intraocular foreign body; MMC Z mitomycin-C; MRSA Z methicillin-resistant Staphylococcus aureus;OD Z right eye; OSZ left eye; P acnesZProprionibacterium acnes; Phaco/IOLZ phacoemulsificationwith intraocular lens implantation; trabZ trabeculectomy

hypopyon and fibrin in the anterior chamber. Dilated fundusexamination revealed severe vitritis. Because of a suspicionof endophthalmitis, a vitreous sample was obtained forculture and intravitreal injections of ceftazidime 2 mgand vancomycin 1 mg were given. The patient was alsotreated with hourly topical fortified ceftazidime (50 mg/mL)and vancomycin (50 mg/mL) eyedrops. Cultures of thecorneal scraping, conjunctival swab, and vitreous samplingshowed no growth. Culture of the eyelids grew pansensitiveStaphylococcus aureus. Two months after the initialpresentation, the corneal ulcer had completely healed andthe BSCVA had returned to 20/20.

Case 2

A 74-year-old man had uneventful combined phacoemul-sification with PC IOL implantation and separate-sitetrabeculectomywithmitomycin-C in the left eye. The tempo-ral corneal incision was closed with 2 sutures, and thetrabeculectomy was performed superiorly. The postopera-tive BSCVA was 20/20. Thirty-three months after surgery,the patient presented with a 10-day history of redness andeyelid swelling. The visual acuity in the left eye was 20/25on presentation. On examination 1 corneal suture was bro-ken and exposed but no infiltrate was seen. The suture wasremoved for culture, and topical moxifloxacin eyedropswere started hourly. The culture grew methicillin-resistantStaphylococcus aureus (MRSA). By the following day, the cor-nea had developed a stromal abscess at the site of the brokensuture a hypopyon and had formed. Visual acuity decreasedto 20/50, but the posterior segment was not involved. The pa-tient was treated with hourly topical fortified vancomycin (50mg/mL) and gentamicin (14 mg/mL) eyedrops in additionto hourly topical moxifloxacin. Although the visual acuity ini-tially decreased to 20/200, onemonth later theulcer hadhealedand the BSCVA had improved to 20/25 (Table 1).

Case 3

A 28-year-old man sustained a penetrating injury to theright eye from a metallic foreign body while working onhis car. Visual acuity on initial examination with pinholewas 20/30 in the injured eye. Phacoemulsification with PCIOL implantation followed immediately by pars planavitrectomy was performed to remove the foreign body.The temporal corneal incision was closed with a single 10-0

J CATARACT REFRACT SU

nylon suture. At the 6-week examination, the visual acuitywas 20/40. One week later, the patient presented with lightsensitivity and discharge from the right eye. Two dendriticcorneal epithelial defects were present; one was adjacent tothe suture temporally and the other, near the superior lim-bus. The patient was treated with topical trifluoridine eye-drops 6 times daily. Cultures and direct fluorescentantibody testing confirmed the clinical diagnosis of herpessimplex virus keratitis. Two weeks later, the corneal suturewas loose and an ulcer had developed. Corneal scrapingfor cultures was performed, and the patient was treatedwith topical fortified vancomycin (50 mg/mL) and gentami-cin (14 mg/mL) eyedrops hourly. Bacterial cultures of thesuture grew Propionibacterium acnes. Antibiotic sensitivitywas not determined. At 2 months, the ulcer had healedand the visual acuity had improved to 20/25 (Table 1).

DISCUSSION

There is wide variability in the management of thecorneal incision in clear corneal cataract surgery. Al-though it is known that nylon sutures tend to degradeor break within 2 to 3 years,9 some ophthalmologistsroutinely leave these sutures in place indefinitely. Cer-tainly, there is a small risk for complications occurringfrom routine corneal suture removal; eg, infection orwound leaks are known to occur in approximately4% of cases of suture removal after PKP.12,13 However,the theoretical risk for this after small-incision cataractsurgery is likely much lower. We are unaware of suchcomplications occurring after routine suture removalat our institution.

To our knowledge, corneal infectious complicationsarising from these sutures after clear corneal incisionphacoemulsification surgery have not been the subjectof any published study. The only 2 related studies8,11

report corneal infections leading to endophthalmitisafter extracapsular cataract surgery. In addition, Kehdiet al.14 and Cosar et al.15 report a combined 12 patientswith corneal wound infections after sutureless clearcorneal cataract surgery.

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941CASE REPORT: SUTURE-RELATED CORNEAL INFECTIONS

In our 3 cases, appropriate treatment preventedpotentially visually devastating outcomes. In the firstpatient, early suspicion of endophthalmitis that wastreated with an injection of intravitreal antibioticagents may have been crucial to the good outcome.In addition, since the infection site was peripheral inall 3 cases, no corneal scarring of the visual axis oc-curred and visual recovery to near baseline levelswas achieved in each case. Notably, no corneal infec-tion was noted in Cases 1 and 2 until after the brokensuture was removed. This suggests that bacterial path-ogens may have been introduced if the trailing end ofthe exposed suture was pulled through the cornea.

Multiple simultaneous procedures were performedin Cases 2 and 3. However, in the second patient,who also had trabeculectomy, there was no involve-ment of the bleb and the infection was clearly associ-ated with a broken suture. In the third patient, thecorneal infection would have occurred much morerapidly if had been caused by organisms inoculatedby the foreign body. Given the range of the time to de-velopment of the corneal infections in these 2 cases, itis unlikely that the combined surgery in Case 2 or thetrauma itself in Case 3 affected the development of theinfections.

We believe that awareness of potential complica-tions of corneal sutures is important for cataract sur-geons. We found only 3 cases of suture-relatedcorneal infectious complications in 2409 clear cornealcataract surgeries in which a suture was placed overa 5.5 year period at our institution. All 3 of these casesoccurred among the 650 cases in which the suture wasnot removed by 2 months postoperatively. There wereno cases of suture-related complications of the 1759cases in which the suture was removed within the first2 months of surgery.

More cases of suture-related corneal infections mayhave occurred in the 650 cases in which the suture wasnot removed by 2 months postoperatively because thepatients may have followed up with their local oph-thalmologist. However, our clinical practice doeshave a very high rate of patient follow-up aftersurgery. In addition, patients who had cataract sur-gery within the past 2 years will likely be at risk forsuture-related infections within the next year or twoas the sutures degrade and possibly become exposed.Further, there may have been cases in which suture-related corneal infections had progressed to endoph-thalmitis at presentation; therefore, we may havemissed these cases if they had been coded asendophthalmitis.

Because of thepotentially significantmorbidity of thisrare complication, we believe that sutures should beremoved routinely in the postoperative period withinthe first month after surgery. This recommendation is

J CATARACT REFRACT SUR

especially importantgiven the recent study16 suggestingthat the use of a suture to close a clear corneal cataractsurgery incision may contribute to a decreased rate ofendophthalmitis. Certainly, in cases in which a sutureis placed in an extremely unstable incision, such as onethat is very short or one that experienced an incisionburn, the suture could be left in place for a longer periodof time.

However, we feel that planned suture removal be-fore suture exposure and contamination is critical toavoid introducing environmental pathogens to thecornea, as demonstrated by Cases 1 and 2. Whileeach surgeon removes sutures differently, we recom-mend pretreatment with a broad-spectrum antibioticeyedrop. The suture should be cut at one end soa minimal amount of suture on the ocular surface isdragged through the corneal stroma and incision in-terface. Topical broad-spectrum antibiotic eyedropsare then recommended for at least a few days to en-sure coverage during reepithelialization.

In addition, prior to planned suture removal, all pa-tients in whom corneal sutures were placed duringsurgery should be instructed to call their physician ifthey notice foreign-body sensation, irritation, pain,or injection as this could represent the earliest symp-toms of a broken or exposed suture. If suture-relatedinfections occur, the suture should be removed and ag-gressive treatment with fortified antibiotic agents isrecommended. Further study of the incidence of thiscomplication is warranted.

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