Elsevier

The Ocular Surface

Volume 18, Issue 4, October 2020, Pages 795-800
The Ocular Surface

Original Research
Efficacy of cyanoacrylate tissue adhesive in the management of corneal thinning and perforation due to microbial keratitis

https://doi.org/10.1016/j.jtos.2020.08.001Get rights and content

Abstract

Purpose

Report the efficacy of cyanoacrylate tissue adhesive (CTA) application in the management of corneal thinning and perforations associated with microbial keratitis.

Methods

A retrospective review of consecutive patients who underwent CTA application for corneal thinning and perforation secondary to microbiologically proven infectious keratitis between 2001 and 2018 at a single center. We defined successful CTA application as an intact globe without tectonic surgical intervention.

Results

The cohort included 67 patients, and 37 presented with corneal perforation while 30 had corneal thinning. The perforation/thinning was central/paracentral in 43 eyes and peripheral in 23 eyes. The underlying infectious etiologies were monomicrobial in 42 cases (35 bacterial, 3 fungal, 2 viral, and 2 acanthamoeba cases) and polymicrobial in 25 cases (22 polybacterial cases and 3 cases with a combination of Gram positive bacteria and fungus). The median duration of glue retention was 29 days. The CTA success rate was 73%, 64%, and 44% at 10, 30, and 180 days, respectively. CTA application appears more successful in monomicrobial (vs. polymicrobial) and Gram positive bacterial (vs. Gram negative) keratitis but the differences are statistically non-significant. The location of perforation/thinning and the use of topical corticosteroid were not associated with CTA failure.

Conclusion

CTA was moderately effective in restoring globe integrity in severe corneal thinning and perforation secondary to microbial keratitis in the short term. However the majority of patients require tectonic surgical intervention within 6 months. CTA application success is not significantly associated with the location of thinning/perforation or the use of topical corticosteroid.

Introduction

Microbial keratitis is a significant cause of monocular blindness across the world. Every year an estimated 1.5 to 2 million people lose their vision as a consequence of microbial keratitis across the globe [1]. In the United States, approximately 1 million patients visit health practitioners and 58,000 patients visit emergency departments for the treatment of microbial keratitis annually [2]. Severe stromal thinning in cases of microbial keratitis can result in significant ocular morbidity, and recalcitrant cases often result in corneal perforation. Such cases are considered an ophthalmic emergency and require urgent intervention to maintain globe integrity. Inadequate management of corneal perforation may result in catastrophic sequelae such as endophthalmitis, suprachoroidal hemorrhage, vision loss, and enucleation.

Cyanoacrylate was first discovered by Coover and colleagues in 1942, at Kodak Research Laboratories. In 1959, they reported the unique adhesive properties of the polymer and suggested its possible use for the closure of surgical incisions. Ever since, the application of Cyanoacrylate tissue adhesive (CTA) has become the initial treatment of choice for severe corneal thinning and perforation as a temporizing measure to provide tectonic strength to the affected corneal tissue. Before application, the esters of cyanoacrylate exist as monomers in a viscous liquid state. Upon application, the monomers are exposed to the anions from the tissue, which triggers the polymerization reaction and promotes its binding to the tissue. In 1968, Webster et al. first reported CTA application for the repair of a perforated corneal ulcer caused by Moraxella lacunata infection [3]. Since then, multiple reports have highlighted the efficacy of CTA application in treating corneal perforation including due to microbial keratitis [[4], [5], [6]]. However, the current literature lacks evidence comparing the efficacy of CTA application in management of keratitis cases caused by various etiologies. In this retrospective case series, we report the clinical characteristics and outcomes of CTA application in 67 eyes diagnosed with keratitis due to diverse causative organisms at the Cornea Service of the Massachusetts Eye and Ear, Boston between 2001 and 2018.

Section snippets

Methods

We obtained the approval of the Institutional Review Board/Ethics Committee at Massachusetts Eye and Ear for this study. The study was conducted in compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and adhered to the tenants of the Declaration of Helsinki.

We performed a retrospective review of the clinical charts of consecutive patients who were treated for corneal perforation or thinning associated with infectious keratitis at the Cornea Service of

Results

The cohort included 67 patients with a median age of 67 years, and 39 (58%) were women. The detailed demographics and clinical characteristics of 67 eyes of 67 patients at presentation are recorded in Table 1. Amongst the patients, 58 (87%) had systemic condition(s), with hypertension being the most common (30, 45%), followed by autoimmune diseases (21, 31%) and hypercholesterolemia (15, 22%). Fourteen patients (21%) were prescribed systemic immunosuppressants, including oral corticosteroids

Discussion

Our study, including 67 eyes, is the one of the largest retrospective case series reporting the efficacy of CTA in fungal, bacterial, viral, amoebic as well as polymicrobial infectious keratitis. The majority of these cases are due to bacterial etiologies. Our data demonstrate that patients often require more than one CTA application and the median retention of CTA is 29 days. CTA application is moderately successful in the short term but the majority of patients require tectonic procedures to

Funding support

This study was supported by the National Eye Institute/National Institutes of Health Grant 5K12EY016335 to JY (trainee).

Declaration of competing interestCOI

The authors declare no financial conflicts of interest.

Author contributions

R.B.S., J.Y. and R.D. designed the study; R.B.S., A.Y., and S.Z. acquired data; R.B.S., S.Z. and J.Y. analyzed the data; R.B.S., A.Y. and J.Y. prepared the manuscript; R.B.S., T.H.D., J.Y. revised the manuscript; J.Y. and R.D. supervised the study; all authors read and approved the final manuscript.

Acknowledgements

We would like to thank Dr. Man Yu and Dr. Rani Al-Karmi, for their assistance in the study.

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