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Clinicopathologic Reports, Case Reports, and Small Case Series
September 2003

Improved Technique for Temporary Tarsorrhaphy With a New Cyanoacrylate Gel

Arch Ophthalmol. 2003;121(9):1336-1337. doi:10.1001/archopht.121.9.1336

The use of cyanoacrylate adhesive to form a temporary tarsorrhaphy was first reported by Schimek and Ballou in 1966.1 They applied Eastman 910 monomer (methyl 2-cyanoacrylate), a clear, colorless liquid adhesive, to the upper eyelashes of 4 patients via a cotton-tipped applicator or the metal spear from the tube and approximated the eyelashes to the skin of the lower eyelid. Numerous reports have discussed accidental tarsorrhaphy of the eyelids and eyelashes from accidental splashing of acrylic adhesive into the eye.2,3 Other studies have shown the efficacy of using either fibrin glue or cyanoacrylate glue to close corneal perforations up to 3 mm in diameter.4,5 In 1991, Donnenfeld et al6 discussed the technique of applying liquid cyanoacrylate with an applicator tip to the upper and lower eyelashes to form a temporary tarsorrhaphy in patients who are unsuitable for more invasive or permanent procedures. We report that the use of the new gel form of cyanoacrylate facilitates the application process, affords better control of tarsorrhaphy length, diminishes any secondary abrasions from applying the liquid adhesive from the standard tube, and reduces the possibility that the glue will spill over the eyelid margin and solidify in the fornix.

Report of a Case

An 81-year-old black woman sought treatment at our eye clinic for left eye pain. She was currently admitted to the hospital for a cardiac workup secondary to chest pain. Her medical history was significant for hypertension, diabetes mellitus, atrial fibrillation, and glaucoma. She was being treated with warfarin sodium, heparin, oral hypoglycemics, and atenolol. Her ocular history revealed glaucoma, bilateral cataract extraction with implants, and a left corneal transplantation, although the patient did not remember exactly when any of the procedures had been performed.

Visual acuity was 20/40 OD and 20/400 OS at 14 inches without correction. Her pupils were unresponsive secondary to prior surgery. She demonstrated full ocular motility and intraocular pressure of 10 mmHg OD and 17 mmHg OS with Schiøtz tonometry. Findings from an external lid examination were normal. Her left conjunctiva was slightly hyperemic. The left cornea contained a mildly edematous corneal graft with an epithelial defect in the inferolateral quadrant measuring approximately 2 mm in diameter. There was no anterior chamber reaction. A dilated fundus examination revealed a cup-disc ratio of 0.95% in the right eye but no view of the left fundus. B-scan ultrasonography of the left eye revealed only a posterior vitreous detachment. The patient was prescribed antibiotic prophylaxis for the epithelial defect, frequent corneal lubrication, and a topical glaucoma medication. Over the next 2 days the defect did not heal, so we decided to create a temporary tarsorrhaphy. Because of the patient's hypocoagulable state, we ruled out an invasive tarsorrhaphy procedure.

After informed consent was obtained, sterile cyanoacrylate liquid was applied to the lateral eyelid margins using an applicator tip. This immediately ran over the eyelid margins onto the conjunctiva and extended too far medially onto the eyelids. Most of this material had to be removed because it was noted to have jagged edges as it hardened within the inferior fornix and would have caused further corneal injury if left in place. We then decided to try the new gel form of cyanoacrylate. The cyanoacrylate gel was applied, with an easily controlled amount, to the eyelid margin and eyelashes. The standard applicator tip, supplied with the gel, was used, and we did not need additional tips, syringes, or needles. Owing to the gel's quick hardening and ability to stay in the location in which it was applied, the lateral eyelids now stayed well approximated once closed with the gel, without any escape of the gel medially onto the eyelid margins or posteriorly into the fornix.

The gel is manufactured by Pacer Technology (Rancho Cucamonga, Calif). It is composed of ethyl-2-cyanoacrylate, polymethylmethacrylate, and hydroquinone(0%-1%). The gel has a specific gravity of 1.05 and is polymerized by water, alcohol, amines, alkaline materials, and direct UV exposure.

Comment

The use of cyanoacrylate is an excellent method for creating a temporary tarsorrhaphy in patients unsuitable for more invasive procedures, for temporary eyelid apposition for persistent epithelial defects, or just for ease of use in the office or at the bedside.6 Cyanoacrylate glue is readily available and does not require an operating room setting; application is a relatively easy skill to learn.7 We have observed that use of the gel form of cyanoacrylate makes this simple procedure even easier and more controllable, with less chance of causing an inadvertent corneal abrasion in a patient with an already problematic cornea. Patients will therefore have less discomfort with the procedure because there is a greatly reduced chance of accidentally getting any glue on the ocular surface, thereby removing the possible need for a post-procedure bandage contact lens to cover any iatrogenic abrasions.7 In addition, there is no need for a separate syringe or needle4,5 because the gel comes with an applicator tip. This will help alleviate patient fears because there is now no need to approach the patient with a sharp object, which allows for better patient compliance as the gel is being applied.

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Article Information

The authors have no relevant financial interest in this article.

Corresponding author and reprints: Michael Ehrenhaus, MD, St Joseph's Eye Care Center, 158-40 79th Ave, Flushing, NY 11366 (e-mail: drmike1@optonline.net).

References
1.
Schimek  RABallou  GS Eastman 910 monomer for plastic lid procedures. Am J Ophthalmol. 1966;62953- 955
PubMed
2.
Raynor  LA Treatment for inadvertent cyanoacrylate tarsorrhaphy: case report. Arch Ophthalmol. 1988;1061033
PubMedArticle
3.
Balent  A An accidental tarsorrhaphy caused by acrylic adhesive. Am J Ophthalmol. 1976;82501
PubMed
4.
Sharma  AKaur  RKumar  S  et al.  Fibrin glue versus N-butyl-2-cyanoacrylate in corneal perforations. Ophthalmology. 2003;110291- 298
PubMedArticle
5.
Leahey  ABGottsch  JDStark  WJ Clinical experience with N-butyl cyanoacrylate(Nexacryl) tissue adhesive. Ophthalmology. 1993;100173- 180
PubMedArticle
6.
Donnenfeld  EDPerry  HDNelson  DB Cyanoacrylate temporary tarsorrhaphy in the management of corneal epithelial defects. Ophthalmic Surg. 1991;22591- 593
PubMed
7.
Baker  Schena L Clinical Update: beyond superglue: the search for a better sealant. Eye Net. January2003;21- 23
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