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Abstract

Purpose: To report a case of allergy to the nylon suture material after keratoplasty and its clinical implications Design: Case ReportObservation: Seventy-three year old man underwent penetrating keratoplasty for pseudophakic corneal edema. Post-operatively he had profuse watering, photophobia, lid margin swelling, conjunctival ballooning and corneal edema. Persistent anterior segment and ocular surface inflammation lead to extensive suture track vascularisation giving a 'fiery sun appearance'. Loose sutures required early suture removal by 2 months. Subsequently, anterior segment and ocular surface inflammation decreased. Systemic/topical corticosteroids were tapered. Retrospective diagnosis of allergy to suture material was made.Results and discussion: At 6 months follow-up, patient has BCVA 6/24, normal ocular surface, no intra-ocular inflammation and normal optic disc. This is first report of presumed nylon allergy after keratoplasty. Specific problems like uncontrolled cylinder power, unstable graft-host junction and wound over-ride due to early suture removal were encountered.On post-op day 25, the patient had severe ocular discomfort, profuse watering and photophobia. Conjunctival hyperaemia and chemosis had significantly increased. Cornea showed minimal corneal edema and significant vascularisation along the sutureline. Figure 1d one suture at 12 o'clock had become loose and was removed. Ocular symptoms and signs were persistent despite maximum corticosteroid treatment. The side-effect of the persistent ocular surface inflammation was that 15/16 sutures needed removal within 2 months of surgery. Figure 1e gradually the ocular surface stabilized, symptoms significantly decreased and the patient became comfortable. Ocular surface and anterior segment inflammation decreased over the next 1 month after suture removal. The suture-line showed scarring as a reminiscent of the vascularisation. Topical and systemic corticosteroids were tapered and moxifloxacin eye drops were stopped. At 6 months follow-up, patient has best spectacle corrected visual acuity as 6/24, best contact lens corrected visual acuity as 6/18, a normal ocular surface, no intraocular inflammation and normal optic disc. Figure 1f corneal topography shows a steep cornea with 14.6D cylinder (Figure 2) possibly due to irregular wound healing and wound gape at 4 o clock. He is currently on topical prednisolone 1% 4 times a day and carboxy-methyl-cellulose 0.5% eye drops 4 times a day. (Figure 1a) Pre-operative image showing mild corneal edema, anterior chamber intra-ocular lens with a vitreous tag going upto the corneal wound; Post-operative images at day 4 ( Figure 1b) and day 10 (Figure 1c) showing lid edema and ocular surface inflammation; Increased ocular surface inflammation, conjunctival hyperaemia and radiating suture tract vascularisation giving a 'fiery sun appearance' at day 25 ( Figure 1d DiscussionWe hereby report a case of an elderly gentleman who underwent penetrating keratoplasty for pseudophakic bullous keratopathy. The p...