We read with interest Khurshid and Fahy's1 report of suppurative keratitis arising from retained corneal sutures and leading to endophthalmitis. Monofilament nylon sutures are routinely used in manual extracapsular cataract surgery. Nonabsorbable sutures may occasionally be required during phacoemulsification surgery. As sutureless phacoemulsification increasingly becomes the norm in cataract surgery, health care teams may become less familiar with the hazards of redundant corneal sutures and, importantly, with their prevention.
Suture abscesses can occur if knots are unburied or if nonabsorbable sutures are exposed, loosely placed, or degrade.2 Loose sutures tend to accumulate mucus with subsequent bacterial contamination.2 Redundant corneal sutures thus pose a preventable patient safety risk for potentially devastating ocular infection. Such complications also pose an avoidable economic burden to health care systems.3
Corneal sutures must be removed before discharging patients from ophthalmic care. With the increasing trend toward early discharge from outpatient care with modernized small-incision cataract surgical care, this practice point, although well known, needs continued emphasis. Systems need to be introduced to ensure that nonabsorbable corneal sutures are not left permanently in patients' eyes. Multidisciplinary health care teams need to be aware of this requirement. One way to address this is to introduce specific prebooked suture removal appointments. These or similar organizational strategies to prevent loss of follow-up should be incorporated into postoperative care protocols. The Royal College of Ophthalmologists recommends removal of corneal sutures 3 months following traditional extracapsular cataract surgery.4
Furthermore, patients and their family members or caregivers should be directly involved in understanding this safety issue within their systematic care plans. Barriers and safeguards such as multidisciplinary advice and patient education on corneal suture removal are potential safety solutions to reduce latent health care errors.5 Such defences should be welcomed and occupy a key position in a system's approach to reducing adverse patient safety incidents.
Simon P Kelly FRCSED, FRCOPHTH, FEBO
Rajitha R Ajit FRCSED
Helen M Glenister RN
aBolton and London, United Kingdom
bBolton, United Kingdom
cLondon, United Kingdom
1. Khurshid GS, Fahy GT. Endophthalmitis secondary to corneal sutures: series of delayed-onset keratitis requiring intravitreal antibiotics. J Cataract Refract Surg 2003; 29:1370-1372
2. Heaven CJ, Davison CRN, Cockfort PM. Bacterial contamination of nylon corneal sutures. Eye 1995; 9:116-118
3. Wong T, Ormonde S, Gamble G, McGhee CNJ. Severe infective keratitis leading to hospital admission in New Zealand. Br J Ophthalmol. 2003; 87:1103-1108
4. Cataract Surgery Guidelines. The Royal College of Ophthalmologists, London, 2001
5. Reason J. Human error: models and management. BMJ 2000; 320:768-770