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