Home Print this page Email this page
Users Online: 417


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 10  |  Issue : 2  |  Page : 54-59

Comparison of eye patching with cyanoacrylate glue application for anterior chamber reformation in infected perforated corneal ulcers


Department of Cornea and Refractive Surgery, Sadguru Netra Chikitsalaya, Chitrakoot, Madhya Pradesh, India

Date of Web Publication7-Mar-2019

Correspondence Address:
Dr. Rini Saha
198 McCaul Street, Toronto, Ontario, M5T 1W5, Canada

Login to access the Email id

DOI: 10.4103/sjopthal.sjopthal_24_18

Rights and Permissions
  Abstract 


Objectives: This study was designed with the primary objective to compare between eye patching and cyanoacrylate glue application for anterior chamber (AC) reformation in infected perforated corneal ulcers. Subjects and Methods: This is a nonrandomized prospective comparative study conducted in a tertiary eye hospital. Patients with perforated keratitis were offered either eye patching (Group 1) or cyanoacrylate gluing (Group 2) under hospital admission and medical treatment to reform the AC. Success was defined as a formed AC at the time of discharge from the hospital. Patients were followed up to 1 month after discharge. Normally distributed data were expressed as mean ± standard deviation and skewed data as median. Nominal data between the two groups were compared using Chi-square test or Fisher's exact test. Results: Forty eyes underwent eye patching and 38 eyes cyanoacrylate gluing to reform the AC. The number of eyes with formed AC was more in Group 2 (92%) compared to Group 1 (70%) (P = 0.020). Subgroup analysis on the basis of the size of perforation and size of ulcer showed that AC reformation was better in Group 2 compared to Group 1 in all aspects [Table 1]. In intragroup analysis, success in Group 1 was significantly better in small perforations (P = 0.001) and in small ulcers (P = 0.032) and ulcer in central location (P = 0.004). In Group 2, there was no significant difference in AC reformation between small and large perforation or ulcer. In both groups, AC reformation in peripheral perforations was poor compared to central and paracentral perforations (P = 0.004, 0.032). Conclusions: Cyanoacrylate glue is better than eye patching to restore ocular integrity. However, eye patching showed promising results in subgroup of patients with small perforated ulcers.{Table 1}

Keywords: Corneal ulcer, cyanoacrylate glue, eye patching, infected, perforated


How to cite this article:
Saha R, Parmar GS, Kumar A. Comparison of eye patching with cyanoacrylate glue application for anterior chamber reformation in infected perforated corneal ulcers. Sudanese J Ophthalmol 2018;10:54-9

How to cite this URL:
Saha R, Parmar GS, Kumar A. Comparison of eye patching with cyanoacrylate glue application for anterior chamber reformation in infected perforated corneal ulcers. Sudanese J Ophthalmol [serial online] 2018 [cited 2019 Mar 18];10:54-9. Available from: http://www.sjopthal.net/text.asp?2018/10/2/54/253681




  Introduction Top


Infectious corneal ulcers are a major cause of vision loss globally as well as in the developing countries.[1] Perforated corneal ulcer due to microbial keratitis needs prompt recognition and treatment to preserve useful vision. Failure to diagnose and treat a perforation early can lead to further corneal damage, cataract formation, glaucoma development, endophthalmitis, and loss of the eye. There are several treatment options in an ophthalmologist's armamentarium to maintain the ocular integrity in such eyes based on the size and site of the perforation.[2] Hydrophilic contact lenses, cyanoacrylate glue, fibrin glue, amniotic membrane, conjunctival flaps, corneal patch grafts, sclera patch grafts, penetrating keratoplasty, and lamellar keratoplasty have all been described in the literature in eyes with infected perforated corneal ulcers. All of these have their own advantages and disadvantages along with additional treatment costs incurred.

Simple eye patching has been used successfully to seal small sterile traumatic or nontraumatic corneal perforations.[3] Patching is avoided as the initial therapy of bacterial keratitis because this may result in a microenvironment favorable to accelerated organism replication.[4] Following eradication of the causative bacteria, patching may be applied to assist re-epithelialization. The literature is sparse regarding the role of eye patching in infected perforated corneal ulcers.[5] Hence, this study was designed with the primary aim to compare the effect of eye patching (Group 1) versus application of cyanoacrylate glue and bandage contact lens (BCL) (Group 2) for anterior chamber (AC) reformation in infected perforated corneal ulcers. The secondary aim was to correlate AC reformation with the size of the perforation and ulcer as well as location of the perforations in the two groups.


  Subjects and Methods Top


This was a prospective nonrandomized comparative study done in the cornea department of a tertiary eye care center of Central India over a period of 1.5 years. Institutional ethical clearance was obtained for this study. All patients who presented with a seidel positive perforated corneal ulcer underwent complete ophthalmic evaluation including history (trauma history, duration of symptoms, previous treatment, recurrence, and systemic disease), best-corrected visual acuity (BCVA), digital tension, detailed slit-lamp examination with color-coded diagram (size of the epithelial defect; size and depth of infiltrates; corneal thinning; site, size, and location of corneal perforation [central, paracentral, and peripheral]; and superficial or deep corneal neovascularization were recorded), corneal scrapping from the margin of the infiltrate for direct microscopy (Gram-staining and potassium hydroxide mount), and gentle ultrasonography for posterior segment evaluation. After getting the reports of the direct microscopy, patients with infected keratitis were allocated to the study groups (Group 1 and Group 2). Written informed consent was obtained for participation in the study. All the patients were admitted in the ward for definitive treatment. After 24 h of starting the medical treatment, patients in Group 1 were given overnight eye patching with cotton eye pad and bandage after applying topical antibiotic and cycloplegic eye ointment. In the morning, the eye patch was removed and slit-lamp examination was done to see if the AC reformed. If the AC was formed, then medical treatment was continued for 1 more day under hospital admission, and next day, the patient was discharged after confirming that the AC was still formed, and the patient was symptomatically and clinically better. If AC did not form after 1 night of eye patching, night patching was continued the next night too. If the AC remained collapsed even after 2 nights of eye patching, then patients were considered for other treatment modalities to reform the AC and were excluded from further study. In Group 2, after 24 h of starting the medical treatment, the perforated ulcers were subjected to N-butyl-cyanoacrylate glue and BCL application under full aseptic precaution in the minor ophthalmic operation theater. During the procedure, AC reformation using intracameral air was avoided for the fear of spreading the infection. Next day, patients were assessed on slit lamp for AC formation, presence of glue, and BCL. If AC was not well formed, the surgeon waited for 24 h more for spontaneous AC formation with aqueous secretion. If AC did not form, then alternative surgical methods were considered and these patients were excluded from further study. During hospital admission, patients were offered intensive antimicrobial therapy (on the basis of clinical examination and microbiologic tests) and topical cycloplegic and preservative-free artificial tears. All patients were examined twice a day on slit lamp by a cornea specialist with color-coded diagram to assess for any worsening of the infection. In both the groups, patients in whom the AC reformed were discharged on topical antimicrobials and cycloplegic and preservative-free artificial tears. At discharge, patients were advised not rub or press the eye. They were followed up at 1 week, 2 weeks, and 4 weeks. At follow-up, size and depth of infiltrates, status of AC, and corneal vascularization were assessed. Perforations more than 3 mm, corneal perforations with iris tissue prolapse, sterile corneal ulcers, sloughing corneal ulcers, total corneal ulcers, patients not willing for admission, and patients not giving informed consent were excluded from the study.

Statistical analysis

Sample size was calculated using the formula n = 2σ2 (Zβ + Z α/2)2/difference[2] based on the difference of AC formation between two groups ([n = sample size for each group, σ = average standard deviation (SD) difference signifying mean difference between two groups], Zβ means 80% power, and Z α/2 means desired level of statistical significance). For each group, 36 eyes were required in our study. Statistical evaluation was done using SPSS 20.0 software (IBM, SPSS Inc., Chicago IL, USA). Normally distributed data were expressed as mean ± SD. Nominal data between the two groups were compared using Chi-square test or Fisher's exact test whichever was applicable. Skewed data were expressed as median and interquartile range. P < 0.05 was considered statistically significant.


  Results Top


Forty eyes underwent eye patching (Group 1) and 38 eyes were offered cyanoacrylate gluing with a BCL (Group 2) to reform the AC. The demographic data and the size of the perforation and ulcer in the two groups have been presented in [Table 2]. Duration of symptoms ≤30 days was considered as early and >30 days as late presentation. The causative microorganism and the location of the perforation in the two groups have been shown in [Figure 1] and [Figure 2], respectively. All the above parameters were comparable in the two groups. Success was defined as a formed AC at the time of discharge from the hospital. The number of eyes with formed AC was significantly more in Group 2 compared to Group 1 at 24 h and 48 h of the intervention (P = 0.003 and P = 0.020), respectively [Table 1]. In Group 1, ten patients required two consecutive overnight eye patching to reform the AC, whereas in 18 patients, only one overnight patching was required. We divided the perforations as small (≤2 mm) and large (>2 mm) and the ulcers as small (≤4 mm) and large (>4 mm). Subgroup analysis showed that AC reformation was better in Group 2 compared to Group 1 in all the above subgroups (P = 0.058, 0.028, 0.019, and 0.046, respectively) [Table 1]. AC reformation in peripheral perforations was also better in Group 2 (P = 0.076). In intragroup analysis, AC formation with eye patching [Table 3] was significantly better in small perforations compared to large (P = 0.001) and also in small ulcers compared to larger ulcers (P = 0.032). Peripheral perforations had less success with eye patching compared to central and paracentral perforations (P = 0.004). In glue and BCL intragroup analysis [Table 4], we found no significant difference in AC reformation in small and large perforations (P = 0.081) and small and large ulcers (P = 0.542) although the results in peripheral perforations were poor compared to central and paracentral perforations (P = 0.032). During hospital admission, none of the patients showed any worsening of the ulcer in either group. At follow-up, all patients in Group 1 had formed AC with healing ulcers though localized iridocorneal adhesions had formed in four patients. The mean logMAR vision at 1-month follow-up was 1.74 ± 0.91 (range: 0.5–3) with 19 patients (67.85%) showing improved BCVA compared to BCVA at presentation. In Group 2, at follow-up, two patients had lost BCL with foreign body sensation and giant papillary conjunctivitis due to the glue, two patients had flat AC due to the dislodgement of glue, one patient had worsening of keratitis, and one patient came with secondary fungal keratitis. Corneal perforation and ulcer presented in color diagram [Figure 3] and [Figure 4].
Table 1: Primary and secondary objectives in the two groups

Click here to view
Table 2: Demographic and initial ophthalmic findings in the two groups

Click here to view
Figure 1: Causative microorganism

Click here to view
Figure 2: Location of perforation

Click here to view
Table 3: Intragroup analysis of variables in Group 1 (eye patching)

Click here to view
Table 4: Intragroup analysis of variables in Group 2 (glue bandage contact lens)

Click here to view
Figure 3: Picture showing corneal ulcer, perforation, and hypopyon

Click here to view
Figure 4: Color diagram showing corneal ulcer, perforation, and hypopyon

Click here to view



  Discussion Top


The use of cyanoacrylate glues has been reported as early as the 1960s for the repair of corneal perforations. It is used “off-label” as an effective therapeutic option in certain ophthalmic settings such as sealing small corneal perforations (≤3 mm),[5],[6],[7],[8],[9],[10] providing tissue strength in impending perforations and descemetoceles and preemptive treatment of progressive corneal thinning disorders.[6],[11] Although eye patching has been used in small sterile perforations, its use in infective perforated ulcers is limited[5] due to the risk of flaring up of infection.[4] This nonrandomized, prospective clinical study demonstrated that both eye patching and cyanoacrylate glue are effective in AC reformation and healing of infected corneal perforations. We included infected corneal ulcers with perforations up to 3 mm in our study. Lekskul et al. had also tried eye patching as a means to restore the integrity of the globe in infected perforated ulcers, but their inclusion criteria were perforations ≤1 mm in size without any active infection and which could not be glued because of an ectatic cornea. They did eye patching in 13 out of 40 eyes and were able to achieve tectonic stability initially in all the 13 eyes with an average perforation sealing time of 8.8 days (range: 2–30 days). However, 9 eyes developed repeated perforations.[5] In our study, AC reformation with eye patching alone could be achieved in 70% of eyes at the time of discharge from the hospital which was less than the initial success rate shown by Lekskul et al. because we included infected perforations up to 3-mm size. We did only overnight patching for a maximum of two nights failing which we resorted to other means to restore the ocular integrity to minimize the formation of peripheral anterior synechiae, risk of cataract formation, and intraocular infection. To minimize the risk of flaring up of infection under the eye patch, we admitted the patients and started full medical treatment after obtaining scrapping reports for 24 h before patching the eye. Only, nighttime patching was done with antibiotic and cycloplegic ointment. During daytime, the patch was removed and medical treatment was continued. Patients were assessed twice on the slit lamp with color diagrams everyday to ensure that the infection was not increasing. None of the patients showed worsening of infection. Patching helps AC formation by preventing blinking of the eye and eye movements which in turn help epithelialization over the perforation, thereby sealing the perforation.[4] Stromal swelling also aids in sealing the wound.[5] It can be suggested that at night, eyes are already closed while sleeping, hence limiting eye movements and blinking. However, in patients with infected corneal ulcers, pain and irritation might lead to disturbed sleep, increased blinking, and eye movements even at night and hence the benefit of overnight eye patching. The intragroup analysis for eye patching showed that AC formation was better in small perforations and ulcers compared to larger ones. This could be because larger perforations and ulcers will take more time for epithelialization and stromal swelling to close the leak. Central and paracentral perforations had greater success compared to peripheral perforations as peripheral perforations can be associated with greater stromal thinning leading to microleaks. The success rate did not depend on the duration of presentation and the causative microorganism. At 1-month follow-up, all the ulcers were in healing phase with no recurrent perforations. In our study, 67.85% showed improved BCVA, whereas a study by Lekskul et al. demonstrated visual improvement in 41.66%.[5] AC reformation and medical treatment led to healing of the keratitis and visual gain. Cyanoacrylate tissue adhesive could seal the perforation and form the AC at the time of discharge from the hospital in 92.1% eyes. We preferred N-butyl-2-cyanoacrylate glue because of its optimum polymerization rate, least toxicity, and easy availability. The success rate of cyanoacrylate tissue adhesive in our study was comparable to those reported by Saini et al. (92.5%),[12] Sharma et al. (86.4%),[10] and Kasetsuwan et al. (91%).[13] Our success rate with cyanoacrylate glue was higher than that reported by Tan et al. (67%).[14] This could be because in their retrospective study success was defined as the tissue adhesive sealing the leak until healing by scarring or until planned definitive surgery with the average duration of glue adherence being 99 days (range: 1–1945 days), whereas we defined success as AC reformation at the time of discharge from the hospital and we had a shorter follow-up period of 30 days. Several factors, including size, chronicity, and presence of infiltrate, have been reported to affect the outcome of tissue adhesive application in corneal perforations. In various studies, tissue adhesives have been applied for corneal perforations varying from 0.5 to 3 mm in diameter.[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] In this study, we included patients with corneal perforations up to 3 mm in size. The intragroup analysis in cyanoacrylate gluing showed that there was no significant difference in AC formation based on size of perforation or ulcer, though in small perforations, 96.8% had formed AC, whereas in large perforations, AC was formed in 71.42%. Tan et al. also found no significant difference in success rate based on perforation size[15] though Sharma et al. found that corneal perforations of 2–3 mm were relatively more difficult to manage.[10] Peripheral perforations had poor outcome compared to central and paracentral ones because of poor adherence of cyanoacrylate glue to the conjunctiva.[2] There was no significant difference in success rate based on the presenting duration. The presenting duration in our study actually signified the duration of keratitis and not the duration of perforation. The complications of glue application seen in this study were similar to those reported in previous studies.[5],[10],[15] To our best knowledge, this is the first study comparing the effect of eye patching with cyanoacrylate glue in infected perforated corneal ulcers. Intergroup analysis showed that overall AC reformation was more in glued perforations (92%) compared to simple eye patching (70%). Similarly, AC formation with gluing was better than eye patching in subgroups of small and large perforation and ulcer as well as peripheral perforations. We found that both cyanoacrylate glue and eye patching are effective means to restore ocular integrity in infected perforated corneal ulcers. Eye patching under hospital admission and antimicrobial therapy can be a simple and effective initial treatment option in small perforated corneal ulcers failing which other definitive treatments can be tried. Spontaneous AC reformation together with the medical treatment helped healing of the ulcer and vision improvement on follow-up in this group of patients. Cyanoacrylate glue application can be associated with several complications. Optical keratoplasty can be planned in a noninflamed eye later on for visual rehabilitation with better results. The major limitations of the study were failure to do randomization, single-center study, and a small sample size.


  Conclusions Top


Cyanoacrylate glue is better than eye patching to restore ocular integrity. However, we suggest that eye patching can be safely tried as an initial means to reform the AC in small perforated keratitis under hospital admission and proper medical treatment. The author warrants further randomized controlled study with a larger sample size.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Srinivasan M, Mascarenhas J, Rajaraman R, Ravindran M, Lalitha P, Glidden DV, et al. The steroids for corneal ulcers trial: Study design and baseline characteristics. Arch Ophthalmol 2012;130:151-7.  Back to cited text no. 1
    
2.
Jhanji V, Young AL, Mehta JS, Sharma N, Agarwal T, Vajpayee RB, et al. Management of corneal perforation. Surv Ophthalmol 2011;56:522-38.  Back to cited text no. 2
    
3.
Hori Y, Wantanabe H, Maeda N, Inoue Y, Shimomura Y, Tano Y, et al. Medical treatment of operative corneal perforation caused by laser in situ keratomileusis. Arch Ophthalmol 1999;117:1422-3.  Back to cited text no. 3
    
4.
O'Brien TP. Management of bacterial keratitis: Beyond exorcism towards consideration of organism and host factors. Eye (Lond) 2003;17:957-74.  Back to cited text no. 4
    
5.
Lekskul M, Fracht HU, Cohen EJ, Rapuano CJ, Laibson PR. Nontraumatic corneal perforation. Cornea 2000;19:313-9.  Back to cited text no. 5
    
6.
Chan SM, Boisjoly H. Advances in the use of adhesives in ophthalmology. Curr Opin Ophthalmol 2004;15:305-10.  Back to cited text no. 6
    
7.
Khalifa YM, Bailony MR, Bloomer MM, Killingsworth D, Jeng BH. Management of nontraumatic corneal perforation with tectonic drape patch and cyanoacrylate glue. Cornea 2010;29:1173-5.  Back to cited text no. 7
    
8.
Rana M, Savant V. A brief review of techniques used to seal corneal perforation using cyanoacrylate tissue adhesive. Cont Lens Anterior Eye 2013;36:156-8.  Back to cited text no. 8
    
9.
Kubicz A, Szaliński M, Misiuk-Hojło M. The cyanoacrylate tissue adhesives in treatment diseases of the anterior eye segment. Polim Med 2008;38:41-6.  Back to cited text no. 9
    
10.
Sharma A, Kaur R, Kumar S, Gupta P, Pandav S, Patnaik B, et al. Fibrin glue versus N-butyl-2-cyanoacrylate in corneal perforations. Ophthalmology 2003;110:291-8.  Back to cited text no. 10
    
11.
Agrawal V, Kumar A, Sangwan V, Rao GN. Cyanoacrylate adhesive with conjunctival resection and superficial keratectomy in mooren's ulcer. Indian J Ophthalmol 1996;44:23-7.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Saini JS, Sharma A, Grewal SP. Chronic corneal perforations. Ophthalmic Surg 1992;23:399-402.  Back to cited text no. 12
    
13.
Kasetsuwan N, Sukharoch P, Meesoupong P, Reinprayoom U, Puangsricharern V. Efficacy and safety of ethyl-2-cyanoacrylate adhesives for corneal gluing. Asian Biomed 2013;7:437-41.  Back to cited text no. 13
    
14.
Tan J, Wechsler AW, Watson S. Long-term adhesion of cyanoacrylate on human cornea. Clin Exp Ophthalmol 2014;42:791-3.  Back to cited text no. 14
    
15.
Setlik DE, Seldomridge DL, Adelman RA, Semchyshyn TM, Afshari NA. The effectiveness of isobutyl cyanoacrylate tissue adhesive for the treatment of corneal perforations. Am J Ophthalmol 2005;140:920-1.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Subjects and Methods
Results
Discussion
Conclusions
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed68    
    Printed0    
    Emailed0    
    PDF Downloaded12    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]