Kerala Journal of Ophthalmology

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 34  |  Issue : 2  |  Page : 149--153

Falling prey to superglue ocular injuries: A case series


Agrima Bhatia, S Mohan, Sridhara Reddy 
 Department of Ophthalmology, Command Hospital Air Force Bangalore, Karnataka, India

Correspondence Address:
Dr. Sridhara Reddy
Associate Professor, Department of Ophthalmology, Command Hospital Air Force Bangalore - 560 007, Karnataka
India

Abstract

Aim: Cyanoacrylate synthetic glue is an instant acting adhesive material often used for household, biomedical and industrial requirements. Accidental instillation of glue into eyes seems to be the commonest mode of chemical eye injuries especially in the paediatric and geriatric population. Methods: A series of five cases of synthetic glue eye injuries following accidental instillation into eyes that presented to our hospital were reported. Results: All the cases were managed conservatively as per the current guidelines with good visual outcome. Conclusion: These case series highlight how even daily activities utilizing the superglue may result in unexpected serious eye injuries. Creating awareness and provision of immediate medical aid can prevent ocular morbidity in such eye injuries.



How to cite this article:
Bhatia A, Mohan S, Reddy S. Falling prey to superglue ocular injuries: A case series.Kerala J Ophthalmol 2022;34:149-153


How to cite this URL:
Bhatia A, Mohan S, Reddy S. Falling prey to superglue ocular injuries: A case series. Kerala J Ophthalmol [serial online] 2022 [cited 2022 Dec 4 ];34:149-153
Available from: http://www.kjophthal.com/text.asp?2022/34/2/149/355030


Full Text



 Introduction



Cyanoacrylate glue is an instant acting adhesive material used most often for household, biomedical, and industrial requirements. It is colorless liquid in form with mild pungent odor and packaged in a small plastic container that resembles the packaging of eye drops or ointments. Chemically it is a derivative of Ethyl cyanoacrylate (ECA) and available in market as Superglue, Feviquick, or Powerglue.[1]

Due to its widespread usage, the incidence of accidental, inadvertent cyanoacrylate instillation into eyes occurs as a result of mistakes by patients, carelessness of children playing with the glue, and also as a result of splash accident. On literature review, the first documented case of ocular superglue injury was reported in 1982. Tabatebaei and colleagues reported 105 cases of ocular synthetic glue injury.[2]

This case series reports five cases of ocular injury caused by accidental instillation of cyanoacrylate glue and summarizes the appropriate management based on relevant literature review.

 Case Reports



Case 1

A 5-year-old boy was brought to Emergency department with complaints of discomfort and inability to open right eye (RE) following accidental splashing of uncapped synthetic glue into his RE while taking it out from a cupboard. On examination, there was adhesion of lid margins along with matting of eyelashes [Figure 1]a. Specks of dried synthetic glue were seen on the right cheek and above the right forehead and eyebrow. The eyelids and eyelashes were separated by trimming of the eyelashes under topical 0.5% proparacaine anesthesia. The right eye was irrigated judiciously with Ringer Lactate for 30 min. This helped the child open his eyes completely [Figure 1]b. The slit-lamp examination revealed glue fragments on upper tarsal conjunctiva and cornea. The adherent glue fragments were removed under slit lamp. Fluorescein dye (2%) staining of cornea revealed diffuse staining pattern due to rubbing of glue fragments under matted lids [Figure 1]c. The RE was patched with antibiotic and cycloplegic drops for 24 h. The conjunctival and corneal abrasions healed completely within 48 h. Upon follow-up after 3 weeks, eyelids and trimmed eyelashes were found to be anatomically and functionally normal.{Figure 1}

Case 2

A 4-year-old boy was brought to the Emergency department with history of accidental instillation of synthetic glue in right eye while doing a school papercraft assignment. On examination, lashes of both the eyelids of RE were found to be matted together and the child could not open the RE completely. Eyelashes were trimmed with lash cutting scissors smeared with antibiotic ointment to prevent trimmed lashes falling into the eye. Slit lamp examination revealed corneal epithelial defect from 6 o'clock to 11 o'clock. Eye was patched with antibiotic and cycloplegic drops for 24 h. On follow-up after 48 h and subsequently after 3 weeks, the trimmed eyelashes had grown to normal size in the right eye.

Case 3

A 74-year-old female reported with history of Feviquick injury to left eye (LE) when she mistook its tube for chloramphenicol eye ointment advised to her for treatment of meibomian gland dysfunction. There was a sudden gush of glue, which entered her eye. She complained of redness, pain in her LE, difficulty in opening the eye, and watering. There was swelling of upper eye lid, conjunctiva was congested, and cornea had the glue adherent to it obscuring the visual axis [Figure 2]a. The LE was irrigated with normal saline 5% for 30 min to wash out the glue. Thereafter, on fluorescein staining, there was a central 2 x 1 mm epithelial defect [Figure 2]b. She was prescribed antibiotic and cycloplegic eye drops, which healed the epithelial defect in 24 h.{Figure 2}

Two cases more, one was a 60-year-old male who reported with similar injury with corneal epithelial defect while mending his broken spectacles [Figure 3] and another was a 12-year-old child who sustained this injury while fixing a flower vase [Figure 4]. Both these cases were also managed as previously stated and showed complete recovery.{Figure 3}{Figure 4}

 Discussion



Cyanoacrylate synthetic glue is available from 1958. It has very high tensile strength that rapidly polymerizes on contact with basic substances such as water or blood to form a strong bond. Because it is synthetic and nonbiodegradable, contact with delicate ocular surface induces an inflammatory foreign body reaction including neovascularization and tissue necrosis.[3]

Upon review of literature, the causes of ocular injuries were attributed to misidentification by patients who were prescribed topical eye medications, carelessness, and childhood curiosity. The result is accidental splashing of glue into the eyes while playing with the glue containers and deliberate forcible squirting of glue into eyes during assault. One hundred five cases of superglue injuries of the eyes have been published in the literature in the past 35 years. The most common clinical presentation was sticking of eyelids/eyelashes and inability to open the eyes. The most common signs were tarsorrhaphy-like appearance of the eyelids and conjunctival and corneal abrasion. The management included irrigation of the eye, trimming of eyelashes to remove the glue attached to the lid margins, and removal of the glue with forceps from the conjunctiva and cornea. The corneal abrasion was treated with topical antibiotics, mydriatics/cycloplegics, and eye patching. In some cases, conservative management was given, i.e., antibiotic eye drops and allowing the glue to fall off itself over a period of few days [Table 1].{Table 1}

No serious ocular morbidities were reported due to superglue injury in these studies. The age of patients varied from 3 months to 64 years and 25% of them were children. In our case series, the age ranges from 4 to 74 years and all had corneal epithelial defect. Accidental injury was reported to be the common modality.

Although some studies reveal that superglue tends to bond on the dry surfaces, the actual polymerization/solidification reaction occurs in the presence of hydroxy ions derived from water.[2] Because some studies in the literature established that cyanoacrylate works well in moist conditions, it explains why on instillation the glue bonds with ocular surfaces resulting in sticking of eyelashes or eyelid margins (ankyloblepheron), which is very common in superglue injuries. The patient blinks forcibly as a reflex reaction due to stinging or burning pain in the eye because of its chemical nature and the glue is forcibly pushed onto the lid margin and eyelashes, thereafter solidifies. The glue causes chemical conjunctivitis and keratitis when it comes in contact with conjunctiva or cornea.

There are two main principles in the management of ocular superglue injuries.

To reverse the chemically induced tarsorrhaphy so that comprehensive and detailed ocular examination can be performed and visible superglue can be removed.To identify the ocular damage by fluorescein staining and treat the ocular damage as per the standard protocols. Immediate irrigation of the eyes helps in removing some of the glue and reducing the rate of condensation of the glue and thus preventing ocular damage.

The cyanoacrylate glue can be removed by using acetone,[9] which is a solvent for the glue; however, in the eye, acetone may cause chemical injury to the conjunctiva and cornea. Removal of the glue on the lid margins can be tried by frequent cleaning with acetone swab. This is essential as continuous contact may result in periocular dermatitis. Simple application of antibiotic eye ointment over the glue also helps in teasing out the glue from matted lids.

Use of 3% sodium bicarbonate solution compress may prove to be more conducive in children who are not cooperative for mechanical or surgical release of eyelids.

Application of margarine,[10] high molecular weight oil, over the lid margins and eyelashes can be tried to dissolve the cyanoacrylate bonds on the lid margins. Superglues used domestically are lower alkyl derivatives than those designed for medical use and they have higher tissue toxicity.

Topical ciprofloxacin 0.3% is reported to cause crystalline punctate deposits and delayed healing of the cornea; hence, should be avoided. Instead, we used 0.5% chloramphenicol eye ointment, which is a broad-spectrum antibiotic to prevent the risk of any secondary bacterial infections.

The risk of ocular accidental application of superglues can be reduced by implementing changes in the package of their bottles, which include child proof cap to prevent conventional opening of the bottle, distinctive shape of the bottles, different odor to alert the user, and warning in bold print of light font against dark background on the bottles for better comprehension by geriatric population in view of their presbyopia and decreased contrast sensitivity. Suggestions written on the bottle should encompass keeping them away from easy access to children, and keeping them physically away from bathroom cabinets and dressing table drawers will also lessen the risk of accidental instillation of superglue in the eyes.

 Conclusion



Ocular superglue injury is a preventable cause of traumatic and chemical ophthalmic injury. Pediatric and the geriatric populations are the most vulnerable. Ocular morbidities range over a spectrum of mild to severe injuries, which may even require a surgical intervention. Strict supervision and protective norms should be followed to prevent future recurrences.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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