10 Complications

10.1 Wound Dehiscence

Wound dehiscence is one the most significant complications that can occur. The risk can be markedly reduced by paying careful attention to a number of elements, including proper suture selection, the use of surgical techniques that minimize tension on the wound, employing the proper number and types of stitches, suturing in layers if indicated, proper knot making, and avoiding the use of sutures in the setting of insufficient tissue or poor tissue quality. A wound dehiscence will need to be managed quickly to be successful. The first step is accurately assessing the cause. If simple resuturing is utilized, then it is important to make a meaningful change in suture material, gauge, or technique to avoid a repeat dehiscence.

10.2 Infection

Infection is an inherent risk for any wound. Sutures can reduce that risk substantially by helping to restore natural tissue barriers, and close dead space. However, sutures are also foreign bodies, and therefore can act as a point of entry for microorganisms into a wound. This can be particularly problematic and vision threatening if the infection occurs in association with a corneal or scleral suture. In that situation, the risk of infectious keratitis, scleritis, or endophthalmitis is significant.

Infection risk can be markedly reduced by performing a careful preoperative antimicrobial preparation, debridement of devitalized tissue, maintaining sterility during the suturing, and removing the sutures when they are no longer necessary. Ideally, a suture should be present as long as it is needed and gone when it is not needed.

The design and composition of the suture also figure into the risk for infection. Braided sutures tend to draw fluid in (capillarity) present a higher risk for harboring microorganisms than smooth monofilament sutures with low capillarity. Infected sutures need to be removed, although the use of antibiotics can often buy some time in this regard. Some sutures are manufactured with an antimicrobial additive or coating, but they are not typically for ophthalmic use.

10.3 Granuloma

Because they are a foreign body, sutures can sometimes incite a significant inflammatory reaction and even a foreign body granuloma. The extent to which a suture is likely to cause an inflammatory reaction is known as its biocompatibility. Some sutures are more likely to cause this type of reaction than others. Sutures made of protein (e.g., gut, silk) present a greater risk of granuloma formation than monofilament polymers. Treating the inflammation may require the use of topical ophthalmic steroids or even removal of the sutures.

10.4 Tissue Breakdown and Scarring

If sutures are tied too tightly, or if their tension is increased due to tissue swelling, there can be mechanical damage to the tissues as well as compromise of the blood supply. This in turn can cause the edges to undergo localized necrosis or atrophy, leading to increased scarring or possible wound dehiscence. The best way to prevent this complication is to avoid tying the sutures excessively tight, using longer bites on each side of the wound when tension exists and doing whatever is necessary surgically to reduce wound tension prior to suturing. When horizontal mattress sutures are used on the skin, circulation to the wound edges can be improved, and the chances for suture erosion into the skin greatly reduced, by the use of protective bolsters placed between the thread and the skin ( Fig. 10.1).

10.5 Suture Marks (i.e., Railroad Tracks) in the Skin

Unsightly suture marks in the skin represent a cosmetic complication of suturing. The risk and severity can be reduced by employing the smallest gauge suture that will provide sufficient tensile strength and removing the suture as soon as possible. Using the most biocompatible suture (e.g., Prolene or nylon rather than Vicryl, gut, or silk) available will also help. Tension on the incision is another risk factor, as it tends to stretch the tissue and create wider openings in the skin surrounding the thread. The use of deep, absorbable sutures can help greatly to reduce the wound tension at the surface. Finally, the use of a running subcuticular technique can eliminate the possibility of suture marks altogether, but is a more technically demanding technique that requires an essentially straight wound with sharp edges and virtually no tension.

Fig. 10.1 Protective bolsters fashioned from plastic tubing taken from a butterfly needle (e.g., tubing of the appropriate length is divided longitudinally using scissors). Bolsters may be used to reduce the pressure on the surface of the tissue in a horizontal mattress suture. The use of the bolsters greatly reduces the chances of erosion of the suture into the tissue. This helps maintain tension and evenly distributes the pressure along the wound edge, helping to preserve circulation.

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