The Use of N-Butyl Cyanoacrylate (Indermil)in Lateral Tarsorrhaphy

Exposure keratitis occurs in facial nerve palsy and may lead to visualloss resulting from corneal damage unless it is treated appropriately. Tarsorrhaphymay be required in more severe cases. This report describes a simple way ofperforming temporary tarsorrhaphy in the outpatient setting.

Three consecutive patients with exposure keratopathy were treated with N-butyl-2-cyanoacrylate (Indermil; Henkel Loctite Corporation,Dublin, Ireland) tarsorrhaphy. Indermil-assisted tarsorrhaphy is simple andis easily performed in the outpatient setting. The eyelid is cleaned withisotonic sodium chloride solution and thoroughly dried with a cotton bud.The patient is instructed to close his or her eyes, and Indermil is applieddirectly to the eyelid margin (Figure 1).The glue should be applied as a thin film by mounting a Southampton (Figure 2) or lacrimal cannula at the endof the tube. Light pressure is then applied to the eyelid margins with cottonbuds for 30 seconds to enhance adhesion. The patient is advised to avoid wettingthe eyelids for the next few hours.

Case 1. A 45-year-old man was seen in the eye casualtyservice, complaining of decreased vision in the right eye. Four weeks previously,he had undergone surgery to remove an acoustic neuroma. An examination revealeda large central corneal abrasion in the right eye, with absent corneal sensationand lower motor neuron facial nerve palsy (Figure 3).

Conservative treatment with topical lubricants and antibiotics failed.The patient was offered surgical tarsorrhaphy, but the offer was declined.Instead, Indermil was used to close the lateral eyelids (Figure 4). The tarsorrhaphy was satisfactory and lasted 4 days,during which the epithelial defect decreased in size. Thereafter, tarsorrhaphywas repeated twice without complications. The second application lasted 7days, and the third lasted 6 days. The corneal defect healed completely afterthe third application.

Case 2. A 17-year-old woman was referred to the eye casualtyservice with a 5-day history of left-sided Bell palsy associated with a painfuleye. Examination revealed 4 mm of lagophthalmos associated with poor Bellphenomenon and a corneal abrasion. Chloramphenicol ointment was prescribed,and the patient was advised to tape her left eyelid shut at night. Four dayslater, corneal exposure with a persistent corneal abrasion was still evident.Surgical tarsorrhaphy was refused; however, the patient consented to tarsorrhaphywith Indermil. The tarsorrhaphy lasted 7 days, during which the corneal abrasionhealed. Function of the left facial muscles was restored during this period,and the exposure keratopathy resolved.

Case 3. A 40-year-old man was seen in the eye casualtywith a 4-day history of facial nerve palsy secondary to herpes zoster infection.Corneal exposure with a central abrasion was evident. There was 5 mm of lagophthalmos.He was prescribed chloramphenicol ointment and advised to tape his eyelidsshut at night. He subsequently developed a skin allergy to the tape and discontinuedits use. A subsequent examination found a persistent central corneal abrasion.The patient refused surgical tarsorrhaphy but was agreeable to lateral tarsorrhaphywith Indermil. The first tarsorrhaphy lasted 6 days but his lower eyelid functionremained poor, and worsening of the exposure keratitis occurred over the next5 days. Glue tarsorrhaphy with Indermil was performed on 2 other occasions,each lasting 7 days. At the end of the third application, the corneal defecthad healed and eyelid function recovered satisfactorily.

Exposure keratitis is a complication of facial nerve palsy. Withouttreatment, this may lead to corneal ulceration with severe visual loss fromscarring and infection. In mild cases, exposure keratopathy can be managedconservatively with copious lubricants and eyelid taping, but in severelyaffected corneas, eyelid closure may be required to maintain corneal integrity.Surgical tarsorrhaphy and botulinum toxin–induced ptosis are 2 well-recognizedmethods of providing corneal protection. Both are effective but have theirdisadvantages.

Surgical tarsorraphy may be divided into suture tarsorrhaphy over bolsters(for short-term use) and reversible permanent eyelid adhesion tarsorrhaphy(for longer-term use). The former is commonly accepted as the gold standardfor temporary eyelid closure. However, both forms of surgical tarsorrhaphyare time consuming, and there may be a risk of permanent scarring to the eyelidsfrom surgery. In addition, patients often refuse surgical tarsorrhaphy forcosmetic reasons. On the other hand, botulinum toxin may not be availableuniversally because of constraints of cost and expertise. Moreover, the inducedptosis is variable in its onset and duration, and there are risks associatedwith the injection.

An alternative approach is to perform glue-assisted tarsorrhaphy. Indermilis a tissue adhesive (N-butyl-2-cyanoacrylate monomer)that is widely used in surgery for the closure of skin wounds and internalwounds without the need for suturing.¹ Theuse of Indermil has also been described in obstetric and gynecologic procedures,otolaryngologic procedures, hand surgery, and plastic and reconstructive surgery.The use of cyanoacrylate glue has been described previously in the managementof corneal epithelial defects² and otherocular problems.³ However, there has beenlittle documentation to date on the successful use of licensed medical preparationsof tissue glue for tarsorrhaphy.

Indermil-assisted tarsorrhaphy lasts for about a week and can easilybe repeated when necessary. With regard to safety, a previous case serieshas suggested that there is no long-term morbidity from superglue contactwith the eye.⁴ The technique is not a replacementfor surgical tarsorrhaphy; however, it may be considered as an alternativein certain situations. First, the technique can be used to provide short-termcorneal protection prior to recovery of facial nerve palsy. Second, it mayserve as a temporary measure for exposure keratopathy while awaiting moredefinitive treatment. Third, it is of value in patients who refuse surgicalintervention.

Corresponding author and reprints: Li Wern Voon, FRCS(Edin), NuffieldLaboratory of Ophthalmology, University of Oxford, Walton St, Oxford OX2 6AW,England (e-mail: voonlw@yahoo.com).