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Editor,—Cyanoacrylate adhesive, a relatively inert material, may be very useful in sealing small corneal perforations. We report a case where accidental injection of N-butyl cyanoacrylate (tissue adhesive) through the corneal perforation into the anterior chamber resulted in complications and required surgical removal.
A 64 year old man with a history of left sided Bell’s palsy of 6 months’ duration had difficulty with left eyelid closure, requiring a suture tarsorrhaphy and placement of a gold weight in the left upper lid. He went on to develop a descemetocele of the left cornea which eventually perforated. N-butyl cyanoacrylate was applied using a cannula to the corneal perforation site and a bandage contact lens was placed. After noting that the adhesive had entered into the anterior chamber, he was referred.
On initial examination, best corrected visual acuity was right eye 20/25 and left eye hand movements. On slit lamp examination, the left cornea showed a central perforation with overlying cyanoacrylate adhesive which had extended down into the anterior chamber. The central iris was covered with adhesive (Fig 1), creating pupillary block. The patient was given preoperative intravenous mannitol and a penetrating keratoplasty was performed. At the time of surgery, the cyanoacrylate adhesive was firmly adherent to both the corneal endothelium and iris. After trephination, the adhesive was gently stripped off the iris (blunt dissection) using forceps. The lens had spontaneously expulsed from the eye along with vitreous. After removing cortical remnants and performing an open sky anterior vitrectomy, a donor cornea was sutured in place. Eight months after surgery, visual acuity is 20/80 and the graft remains clear.
Tissue adhesives are relatively inert polymers which were first used in 1969 to seal a corneal perforation, thus eliminating the need for ocular surgery.1 In addition, tissue adhesives have been used in the ophthalmic setting for tarsorrhaphy, punctal occlusion, ptosis, retinal holes, and scleral thinning. With corneal perforations, the adhesive creates an inflammatory reaction and host fibrous tissue grows behind the adhesive filling in the gap. The adhesive should only be applied to perforations that are less than 1.5 mm in diameter and should not be used if there is prolapse of intraocular contents. For flat anterior chambers, air or viscoelastic should be used first.
In animal experiments, small amounts of tissue adhesive injected into the anterior chamber created conjunctival vascular engorgement, mild self limited keratitis/uveitis, and localised corneal scarring; however, there was minimal ocular toxicity after 1 year.2If injected in larger amounts, intense inflammation, corneal neovascularisation and necrosis, were seen. Other reported problems with the use of tissue adhesive include symblepharon, giant papillary conjunctivitis, and retinal toxicity.3 In our case, the tissue adhesive created pupillary block. Because of the corneal perforation, intraocular pressure readings were unobtainable. After surgical intervention (penetrating keratoplasty, dissection of adhesive off the iris, self expulsion of lens, open sky vitrectomy), the patient remains comfortable with a clear corneal graft and a good chance of achieving excellent visual acuity. While accidental injection of tissue adhesive into the anterior chamber may be tolerated well with minimum complications, larger amounts should be removed.