Early surgical excision for suture granuloma after strabismus surgery

Purpose: Suture granuloma is a recognized complication of strabismus surgery caused by a foreign body reaction to retained suture material. There is currently no standardized management strategy, although non-surgical treatments such as topical or oral steroids and beta blockers are commonly employed. However, treatment courses are often prolonged, and subsequent surgical excision may still be required. Methods: We describe the case of a nine-year-old female patient who developed large suture granulomas after uncomplicated right eyed lateral rectus recession and medial rectus resection surgery using 6/0 VICRYL. This occurred over the new insertion sites within three weeks despite sterile intraoperative techniques and good post-operative drop compliance. Results: There was no response to initial treatment with hourly dexamethasone 0.1% drops and oral ibuprofen, and repeat orthoptic assessment showed an early deterioration in post-operative control of the deviation. The patient was taken back to theatre for early revision surgery and found to have extensive granulation tissue overlying the retained suture fragments. The sutures and granulation tissue were completely excised, and there was subsequently good healing with no recurrence. A panel of expert opinion was surveyed to review current opinions in managing suture granuloma; this revealed a range of different practices, however very few respondents employed early excision. Conclusion: We suggest that prompt surgical intervention for suture granuloma can produce safe and effective results without the need for prolonged medical therapy and should be employed earlier in the management of severe cases following a short trial of intensive anti-inflammatory medications. Given the comparative rarity of suture granuloma it may be considered for monitoring, for example, by BOSU.