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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 889-890

Atypical early presentation of graft suture infection

Department of Cornea, Ophthalmology, Leicester Royal Infirmary, University Hospitals of Leicester, Leicester, United Kingdom

Date of Submission27-Apr-2022
Date of Acceptance12-Jul-2022
Date of Web Publication11-Oct-2022

Correspondence Address:
Dr. Mercedes Molero-Senosiain
Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW
United Kingdom
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1041_22

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We report an atypical presentation of a corneal graft suture-related abscess. An 80-year-old female with a history of Moraxella and herpetic keratitis successfully treated with penetrating keratoplasty was noted to have a semi-circular pigmented line of keratic precipitates straddling a single suture during a routine follow-up appointment. After 48 hours of oral anti-viral and topical steroid therapy for presumed graft rejection, she developed a suture abscess with hypopyon. Treatment with intensive topical antibiotics was commenced, and the case resulted in complete resolution. Semi-circular endothelial keratic precipitates could be an early sign of suture infection.

Keywords: Atypical sign, graft rejection, keratic precipitates, suture abscess

How to cite this article:
Molero-Senosiain M, Patel A, Savant S, Savant V. Atypical early presentation of graft suture infection. Indian J Ophthalmol Case Rep 2022;2:889-90

How to cite this URL:
Molero-Senosiain M, Patel A, Savant S, Savant V. Atypical early presentation of graft suture infection. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Nov 27];2:889-90. Available from: https://www.ijoreports.in/text.asp?2022/2/4/889/358143

Penetrating keratoplasty (PKP) has been largely replaced in the past 15 years by lamellar keratoplasty, but it is still the preferred surgical treatment for advanced keratoconus and scarring and secondary to infection or trauma and graft failure.[1]

There is some consensus for PKP that sutures should not be removed before 6 months after surgery because of the risk of graft dehiscence.[2]

There are many complications related to nylon monofilament sutures, mainly if they are exposed or loose. Serious complications are suture abscess, suppurative keratitis, endophthalmitis, and graft rejection.[3]

We present the first reported case of a semi-circular line of endothelial keratic precipitates as an early response to pre-clinical corneal suture infection.

  Case Report Top

An 80-year-old female with a known history of herpeptic keratouveitis presented in an eye casualty with left eye blurred vision and pain. Examination showed corneal ulcer with corneal melt. Diagnostic corneal scrapes confirmed  Moraxella More Details keratitis. Despite prompt diagnosis and adequate topical therapy (gentamicin 0,3% and levofloxacin 0,5% every hour), the left eye progressed to corneal perforation. Corneal gluing with a plastic patch was performed. After 2 months of treatment, the eye was quiescent and a tectonic PKP with extra-capsular cataract surgery and insertion of a posterior chamber intra-ocular lens was performed. During early post-operative follow-up, the vision improved to 6/36 unaided and the graft was transparent and clear, with no recurrence of infection.

Three months after surgery, during a routine review, a semi-circular pigmented line of keratic precipitates straddling one suture at the 9 o' clock position was seen, with mild localized graft edema but no fluorescein intake in that area [Figure 1]a. There was mild anterior chamber inflammation. She was diagnosed with presumed endothelial graft rejection and treated with topical dexamethasone 0.1% hourly and systemic Acyclovir 400 mg twice a day orally.
Figure 1: (a). Tectonic penetrating keratoplasty with a pigmented line of keratic precipitates surrounding one of the sutures (red narrows) but no clear infiltration or loose suture. (b). 7 mm hypopyon and abscess over the suture at 9 o'clock

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Forty-eight hours later, the patient presented with hand movement vision and 7 mm hypopyon with dense stromal abscess at the same site as described above [Figure 1]b. The diagnosis was revised to suture-related abscess, and treatment with topical cefuroxime 5% and levofloxacin 0.5% every hour was commenced. Diagnostic corneal scrapes were performed, and the offending suture was removed. Primary culture showed Staphylococcus aureus. After 6 weeks of treatment, the hypopyon and anterior chamber inflammation resolved [Figure 2]a and the corneal graft stromal infiltrate cleared. After 3 months, the visual acuity improved to 6/15 and examination showed anterior peripheral stromal scarring at the site of the suture abscess only [Figure 2]b.
Figure 2: (a). Hypopyon resolving process. (b). Resolved hypopyon and clear graft

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  Discussion Top

National data records in many countries had shown a drop in incidence of PKP along the past 2 decades. For instance, the UK PKP numbers have reduced from 98.3% in 1999 to 46.6% in 2009, and the USA PKP numbers have reduced from 95% in 2005 to 42% in 2014. Corneal blindness is different geographically, depending on ethnicity and prevalence of corneal diseases. Although keratoconus is more frequent in the Middle East, Fuchs dystrophy is more common in Western countries, and infectious keratitis is more prevalent in Southeast Asia.[4]

The most common complications after PKP in patients with infective keratitis are recurrence of infection, rejection, failure, and glaucoma. 25% of corneal graft recipients experience at least one rejection episode, but fortunately, most episodes do not cause irreversible endothelial failure.[5]

The typical presentation of endothelial graft rejection is a linear pigmented line of keratic precipitates, usually horizontal or oblique (Khodadoust line), that first appears at the periphery of the graft and then migrates across it. This line forms a demarcation in the donor cornea between the healthy transparent and an area of corneal graft edema. However, it has been documented that a third of rejection reactions are asymptomatic.[2]

Because our patient had all these signs, our first diagnostic impression was a graft rejection. Because this is a potentially serious complication following PKP, we started intensive topical steroid treatment with dexamethasone 0.1% hourly.[6]

The typical presentation of a suture abscess is a stromal suppurative infiltrate around the base of the suture surrounded by edema and sometimes anterior chamber reaction with or without hypopyon.[7]

To our knowledge, this is the first reported case of a semi-circular line of endothelial keratic precipitates as an early response to pre-clinical corneal suture infection.

  Conclusion Top

In conclusion, suture infection should always be considered as a possible diagnosis. Particular attention should be given to examine the nearby corneal sutures to identify any possible early infection. Early suture infiltrate can be difficult to distinguish from superficial corneal scarring near the host end of the suture. Prompt and intensive treatment is mandatory to avoid subsequent graft rejection or failure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Singh R, Gupta N, Vanathi M, Tandon R. Corneal transplantation in the modern era. Indian J Med Res 2019;150:7-22.  Back to cited text no. 1
[PUBMED]  [Full text]  
Leahey AB, Avery RL, Gottsch JD, Mallette RA, Stark WJ. Suture abscesses after penetrating keratoplasty. Cornea 1993;12:489-92.  Back to cited text no. 2
Cameron JA, Huaman A. Corneoscleral abscess resulting from a broken suture after cataract surgery. J Cataract Refract Surg 1994;20:82-3.  Back to cited text no. 3
Shin KY, Lim DH, Han K, Chung T-Y. Higher incidence of penetrating keratoplasty having effects on repeated keratoplasty in South Korea: A nationwide population-based study. PLoS One 2020;15:e0235233.  Back to cited text no. 4
Lin HC, Ong SJ, Chao AN. Eye preservation tectonic graft using glycerol-preserved donor cornea. Eye 2012;26:1446-50.  Back to cited text no. 5
Panda A, Vanathi M, Kumar A, Dash Y, Priya S. Corneal graft rejection. Surv Ophthalmol 2007;52:375-96.  Back to cited text no. 6
Acharya M, Farooqui JH, Jain S, Mathur U. Pearls and paradigms in Infective Keratitis. Rom J Ophthalmol 2019;63:119-27.  Back to cited text no. 7


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