CASE REPORT

Endophthalmitis after corneal suture removal

Staropoli, Patrick C. MD; Yannuzzi, Nicolas A. MD; Jacobs, David MD; Flynn, Harry W. Jr MD

Author Information
JCRS Online Case Reports 10(2):p e00073, April 2022. | DOI: 10.1097/j.jcro.0000000000000073
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Abstract

Endophthalmitis is a severe ocular complication occurring after surgery, trauma, and intravitreal injections. Streptococcus sp., a gram-positive cocci, is the second most common cause of postcataract surgery endophthalmitis and the leading cause of late bleb-related endophthalmitis.1,2 Compared with coagulase-negative staphylococcal infection, the most common cause of endophthalmitis overall, streptococcal endophthalmitis generally has poorer visual outcomes.3

Endophthalmitis after corneal suture removal is a rare entity with a fulminant course. It is commonly caused by Streptococcus species and has been reported more frequently in pediatric populations.4 This report describes 2 cases of streptococcal endophthalmitis after corneal suture removal without the use of povidone–iodine as antimicrobial prophylaxis.

Patient Consent Statement

One patient provide written informed consent. The other patient and relatives were unable to be reached. The medical team takes full responsibility for anonymization. Institutional Review Board (IRB)/ethics committee approval was obtained for this case report.

CASE REPORTS

Case 1

An 83-year-old woman with an underrotated and underpowered toric intraocular lens (IOL) underwent IOL exchange. On postoperative week 5, her vision was 20/50. A nylon suture was removed from the main temporal corneal wound. Three days later, she developed eye pain and presented with light perception (LP) vision, an infiltrate at the suture site, 1 mm hypopyon, and diffuse vitreous opacities on B-scan ultrasonography (Figure 1). Tap and inject of vancomycin 1 mg/0.1 LISTNUM and ceftazidime 2.25 mg/0.1 cc was performed by the patient’s cataract surgeon, and then, she was referred to the retina specialist who completed pars plans vitrectomy, anterior chamber washout, and partial air–fluid exchange with repeat injections the same afternoon (Figure 1). Topical fortified vancomycin 25 mg/mL, tobramycin 14 mg/mL, difluprednate 0.05%, and atropine 1% were prescribed. The corneal culture grew pan-sensitive Streptococcus pneumoniae. The vitreous culture showed negative results. Vision decreased to no LP. The patient underwent enucleation 6 weeks later for uncontrolled pain.

F1
Figure 1.:
A: Operating room microscope photograph of the right eye demonstrating diffuse hemorrhagic chemosis, corneal edema, inferotemporal infiltrate, and anterior chamber fibrinous reaction. B: Anterior chamber washout. C: 25-gauge pars plana vitrectomy with removal of vitreous membranes and posterior segment views of (D) extensive intraretinal hemorrhages.

Case 2

A 64-year-old man with a history of radial keratotomy underwent IOL exchange for IOL dislocation in his left eye, during which a radial keratotomy incision dehisced and was closed with nylon sutures. The operative note from the referring physician was not available. At postoperative month 3, the final suture was removed. One day later, he presented with acute pain, hand motion vision, corneal infiltrate, fibrin in the anterior chamber, and vitreous opacities on B-scan (Figure 2). Tap and inject with vancomycin 1 mg/0.1 cc and ceftazidime 2.25 mg/0.1 cc was performed. Vitreous culture demonstrated pan-sensitive alpha-hemolytic Streptococcus sp. Vision decreased to LP. Topical fortified vancomycin 25 mg/mL, tobramycin 14 mg/mL, moxifloxacin 0.5%, prednisolone 1%, and cyclopentolate 1% were prescribed. Because of a poor view through the cornea that prohibited vitrectomy, intravitreal dexamethasone 0.4 mg/0.1 mL and a second dose of vancomycin were given 3 days later. Pain improved significantly although vision remained LP.

F2
Figure 2.:
A: Slitlamp photograph showing conjunctival injection, corneal edema, 2.4 mm hypopyon with anterior chamber fibrinous reaction, and (B) corneal infiltrate in the area of several removed stitches.

Povidone–iodine and topical antibiotic drops were not used during corneal suture removal in either case. Neither patient was immunocompromised or a contact lens wearer. Prophylactic intracameral antibiotics were not given during the original surgery, and the patients were not on any topical medications during the time of suture removal.

DISCUSSION

Corneal suture removal is a rare cause of endophthalmitis with an incidence limited to case reports. Lack of antimicrobial prophylaxis, premature suture removal, full-thickness suture tracts, late wound dehiscence, and epithelial defects leading to ulceration are believed to increase the risk for endophthalmitis.5 Forstot et al. described 3 cases occurring after corneal suture removal in patients with penetrating keratoplasty. Two cases, which were due to wound dehiscence, occurring as late as 3 days after suture removal. The authors hypothesized that small caliber suture material and chronic topical steroids could predispose to wound dehiscence. They recommended the use of topical antibiotics before and after suture removal.5

Even with prophylactic antibiotics, endophthalmitis is still possible. Culbert and Devenyi presented 3 cases of suture removal–related endophthalmitis after cataract surgery. Prophylactic antibiotics had been used, but povidone–iodine 5% was not applied. The authors argued that povidone–iodine is more effective at decreasing the microbial concentration and should be used in preparation before suture removal.6 Of course, prophylactic povidone–iodine has been shown to lower the rate of postoperative endophthalmitis, particularly when used as an adjunct to topical antibiotics.7,8

There have been several case series regarding endophthalmitis after corneal suture removal. However, many of these cases had identifiable inciting factors such as broken sutures or suture abscesses. For example, Panchal et al. published the largest series on endophthalmitis after corneal suture removal with 11 cases spanning 10 years at multiple facilities.4 Onset was, on average, 5.3 days after suture removal, and the mean age was 15.8 years. Streptococcus pneumoniae was the most common causative organism, followed by Haemophilus influenzae and Achromobacter denitrificans. The authors claimed that povidone–iodine 5% was used before and after suture removal and antibiotics were prescribed for 1 week. The caveat was that 8 of 11 were pediatric cases presenting with loose sutures; the remaining 3 were adults after ruptured globe repair—both were significant risk factors for infection despite prophylactic antimicrobials.4 Similarly, Henry et al. reported 6 patients older than 15 years who had vitreous culture-positive endophthalmitis that developed from culture-positive corneal suture infections on presentation. Of these, 4 had a corneal infiltrate due to a loose or broken suture on presentation and subsequently developed streptococcal endophthalmitis despite antibiotic coverage.9 The 2 cases presented in this report are unique because there was no inciting factor, other than routine corneal suture removal without the use of antibiotic drops or povidone–iodine. Theoretically, in reoperations using the same primary wound, there could be an increased risk of leakage or fishmouthing due to differences in wound healing; however, these 2 cases showed negative results for Seidel test on presentation. Table 1 summarizes the cases of endophthalmitis after cornea suture removal that have been reported without an identifiable inciting factor.

Table 1. - Endophthalmitis reported after suture removal.
Study Patient age (y)/sex Initial VA Original surgery Time since original surgery Time since suture removal Isolate Antimicrobial at time of suture removal Treatment VA at last follow-up
Culbert and Devenyi6 73/F 20/400 Phacoemulsification 3 mo 2 wk NG Topical antibiotic, no Betadine T&I 20/30
Culbert and Devenyi6 80/F 20/400 Phacoemulsification AC IOL 10 wk 1 wk Group G Streptococcus Topical antibiotic, no Betadine T&I CF
Culbert and Devenyi6 83/F CF ECCE 2 mo 7 d Coagulase-negative Staphylococcus spp Topical antibiotic, no Betadine T&I 20/300
Eu Lim, et al.10 77/M 20/800 Phacoemulsification 3 wk 2 wk NG No antimicrobial T&I HM
This study 83/F LP IOL exchange 5 wk 2 d Streptococcus pneumoniae No antimicrobial T&I, PPV Enucleation
This study 64/M HM IOL exchange 3 mo 1 d Alpha-hemolytic Streptococcus sp. No antimicrobial T&I LP
AC = anterior chamber; CF = counting fingers; ECCE = extracapsular cataract extraction; HM = hand motion; LP = light perception; NG = no growth; PPV = pars plana vitrectomy; T&I = tap and injection
All cases listed in this table had no identifiable inciting factor (ie, suture abscess, trauma, and corneal epithelial defect).

Another concern is the time of suture removal. Eu Lim et al. described the case of a 77-year-old man with multiple comorbidities who underwent phacoemulsification. He had a tight suture removed at postoperative week 1 but did not receive povidone–iodine or continue topical antibiotics. Endophthalmitis developed 2 weeks later.10 As cataract surgery becomes more refractive, sutures are used less frequently and removed as soon as possible to diminish astigmatism. Some reports on this subject noted more stable refraction when corneal sutures were removed at 12 weeks.11,12 At our institution, corneal sutures are typically removed between 1 week and 1 month after cataract surgery. In other procedures such as ruptured globe repair or penetrating keratoplasty, corneal sutures are removed in a staged fashion, usually beginning 12 weeks postoperatively. Although optimal timing is debatable, Seidel testing can be considered for all wounds after suture removal. Alternative wound closure options include polyethylene glycol–based sealants that have the benefit of providing a full barrier rather than point tension on the wound. However, the sealant only lasts 48 hours, and its effect on infection rate, particularly in complex cases or reoperations, has not been well studied.

This report demonstrates how eyes without high-risk features can develop endophthalmitis after routine cornea suture removal without antimicrobial coverage. Povidone–iodine antisepsis for endophthalmitis prophylaxis should be considered in this procedure. Although no definitive data is published, the authors also recommend a topical fluoroquinolone or polymyxin-trimethoprim drop for 3 days postprocedure.

WHAT WAS KNOWN

  • Endophthalmitis after uneventful corneal suture removal is a rare but fulminant process.

WHAT THIS PAPER ADDS

  • Antimicrobial coverage for cornea suture removal is an imperative prophylaxis against endophthalmitis.
  • Streptococcal endophthalmitis generally has poor clinical outcomes despite aggressive intervention.

REFERENCES

1. Lalwani GA, Flynn HW, Scott IU, Quinn CM, Berrocal AM, Davis JL, Murray TG, Smiddy WE, Miller D. Acute-onset endophthalmitis after clear corneal cataract surgery (1996–2005). Ophthalmology 2008;115:473–476
2. Leng T, Miller D, Flynn HW Jr, Jacobs DJ, Gedde SJ. Delayed-onset bleb-associated endophthalmitis (1996–2008): causative organisms and visual acuity outcomes. Retina 2011;31:344–352
3. Jones S, Cohen EJ, Arentsen JJ, Laibson PR. Ocular streptococcal infections. Cornea 1988;7:295–299
4. Panchal B, Tyagi M, Pathengay A, Sharma S, Dave VP, Gandhi U, Balakrishnan D, Pappuru RR, Joseph J, Kekunnaya R, Das T. Endophthalmitis following suture removal—clinical outcomes and microbiological profile. Semin Ophthalmol 2019;34:115–123
5. Forstot SL, Abel R Jr, Binder PS. Bacterial endophthalmitis following suture removal after penetrating keratoplasty. Am J Ophthalmol 1975;80:509–512
6. Culbert RB, Devenyi RG. Bacterial endophthalmitis after suture removal. J Cataract Refract Surg 1999;25:725–727
7. Ahmed Y, Scott IU, Pathengay A, Bawdekar A, Flynn HW Jr. Povidone-iodine for endophthalmitis prophylaxis. Am J Ophthalmol 2014;157:503–534
8. Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with topical povidone-iodine. Ophthalmology 1991;98:1769–1775
9. Henry CR, Flynn HW Jr, Miller D, Schefler AC, Forster RK, Alfonso EC. Delayed-onset endophthalmitis associated with corneal suture infections. J Ophthalmic Inflamm Infect 2013;3:51
10. Eu Lim AK, Lim SL, Hussein E. Acute post-cataract-surgery endophthalmitis after suture removal. Philip J Ophthalmol 2006;30:137–139
11. Stanford MR, Fenech T, Hunter PA. Timing of removal of sutures in control of post-operative astigmatism. Eye (Lond) 1993;7:143–147
12. Danjoux JP, Reck AC. Corneal sutures: is routine removal really necessary? Eye (Lond) 1994;8:339–342
Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of ASCRS and ESCRS
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