Clinical profile and management of ocular superglue injuries: Case series and review of literature (2024)

Abstract

Methods

This was a retrospective hospital-based study that included all patients diagnosed with acute OSI between January 2016 and December 2020. The study was approved by the Institutional Ethics Committee and adhered to the tenets of the Declaration of Helsinki. A general consent for examination and documentation of clinical information was taken from all the patients.

All patients ≤18 years were considered in the pediatric group, while the rest were included as adults. For every patient, the demographic data, location, mode of injury, the causative agent, and the time interval between the injury and presentation were collected. The severity of the injury as per the Roper-Hall (RH) grading system and Dua grading system at presentation was collected.[10,11] Specific details like the presenting visual acuity (VA), clinical signs involving the ocular adnexa and the ocular surface, treatment, and duration of follow-up were collected.

A descriptive analysis was performed to characterize the patient’s demographic profile and clinical outcomes. All the data were documented in a Microsoft Excel sheet (version 16.5 Microsoft Corporation, USA). The statistical analysis was performed using Stata statistical software 15 (StataCorp, College Station, Texas). The normality of the data was evaluated with the Shapiro-Wilk test. Mann-Whitney U-test was used to compare the VA between the adult and pediatric groups. A P value of < 0.05 was considered significant.

Results

1. Demographic and baseline characteristics

   A total of 58 patients were included in this study, of which 24 were children (28 eyes) and 34 were adults (38 eyes). The median age at presentation was 22.5 years [interquartile range (IQR): 11.3–31]. The median age was 8 years [IQR: 6.8–13.3] and 31 years [IQR: 25.3–34] in the pediatric and adult groups, respectively. The demographic and the clinical profile of all patients have been presented in Table 1. A female preponderance was seen in the pediatric group (54%, 13/24), whereas among the adults, a male preponderance was seen (62%, 21/34) (P = 0.28) although this was not statistically significant. All the patients in the study sustained accidental OSI. In the pediatric cohort, all cases (24/24, 100%) sustained domestic injuries (home: 19/24, 79%; school: 5/24, 21%). The most common setting in which the OSI occurred was handling of the superglue by the child in the absence of adult supervision (22/24 patients, 92%), while the remaining two children (8%) suffered injuries despite being supervised by an adult, due to accidental eye rubbing with glue smeared fingers. Among the adults, 41% of patients (14/34) sustained OSI at the workplace (office 12/14; factory: 2/14), while 53% (18/34) patients sustained the injury at home. In two patients (6%), the exact location of the injury was not known. Improper handling was the most common risk factor seen in 91% of adults (31/34), followed by glue bottles mistaken for eye drops seen in 9% of cases (3/34).

2. Clinical presentation

   In the pediatric and adult cohorts, 61% (17/28) and 55% (21/38) of eyes sustained Grade 1 injury (Dua and RH), respectively [Table 1]. The remaining 39% of eyes (11/28) in the pediatric group and 45% of eyes (17/38) among the adults presented with a less severe injury such as eyelid involvement and conjunctival congestion, and hence could not be classified according to the available grading systems. The majority of the patients presented to the hospital within 6 hours of the injury (children 19/24, 79%; adults: 23/34, 68%) (P = 0.53) [Table 1]. The median duration from the time of injury to presentation was 2 h, in both groups (IQR pediatric group: 1–4.3; adult group: 1–6). The median VA at presentation was logMAR 0.3 [Snellen equivalent (SE): 20/40; IQR: 0.2–0.4] in the pediatric group and logMAR 0.1 (SE: 20/25; IQR: 0.1–0.3) in the adult group (P = 0.03). At presentation, VA could be recorded only for 14/28 eyes (50%) in the pediatric group. The final median VA was logMAR 0.2 (SE: 20/30; IQR: 0.1–0.3) and logMAR 0 (SE: 20/20; IQR: 0–0.1) in the pediatric (n = 25/28 eyes) and the adult groups, respectively (P = 0.0003). Significant improvement in VA following treatment was seen among the adults (P < 0.0001). However, among children, the improvement in the VA following treatment was not statistically significant (P = 0.56, n = 14).

   Eyelid, conjunctival, and corneal signs at presentation have been elaborated in Table 2. The most common eyelid sign was polymerized glue particles stuck to the eyelids and the eyelashes seen in 50% (14/28) of the pediatric eyes and 53% (20/38) of the adult eyes. Conjunctival congestion was the most common clinical sign involving 71% (20/28) pediatric eyes and 82% (31/38) adult eyes. Corneal epithelial defects were seen in 43% (12/28) pediatric eyes and 45% (17/38) adult eyes [Fig. 1]. The median diameter of the corneal epithelial defect diameter was 5 mm (IQR: 3.8–5.3) and 2 mm (IQR: 2–8.5) in the adult eyes and the pediatric eyes, respectively. In 25% (3/12) pediatric eyes, the size of the corneal epithelial defect could not be measured.

3. Management

   Upon sustaining the chemical injury, immediate ocular irrigation was performed in all patients. In eyes where the eyelids could not be opened due to retained glue (pediatric group: 12/28, 43%; adult group: 8/38, 21%), the eyelids were gently pried apart to complete the ocular examination. In eyes where separation was unsuccessful, trimming of eyelashes was performed (pediatric: 10/28 eyes, 36%; adults: 4/38 eyes, 11%) to separate the eyelids and complete the ocular examination. Separation of eyelids and trimming of eyelashes were performed without any anesthesia in adults and under general anesthesia in children. Examination under anesthesia was required in three pediatric patients (13%) to remove the glue stuck to the eyelashes and the corneal surface. Of these, the eyelids were stuck due to glue in the eyelashes in two patients which was carefully removed with a forceps. In one patient severe eyelid edema prevented separation of the eyelids. This patient also had glue stuck to the corneal surface which had caused an epithelial defect. The glue was carefully removed with a forceps. All the eyes responded with medical management with topical carboxymethylcellulose 0.5% prescribed six times/day. Additionally, topical prednisolone acetate 1%, four times/day with weekly tapering doses, was prescribed in patients with severe ocular surface inflammation with corneal epithelial defect. Moxifloxacin eyedrop 0.5%, four times/day was also prescribed till the resolution of the corneal epithelial defect. None of the eyes required any surgical intervention to promote epithelial healing of the ocular surface. The mean duration of follow-up was 3 days in both pediatric and adult groups (IQR: 1–8.3 and 1–4.3, respectively) (P = 0.56). None of the patients suffered from any long-term ocular complications.

Discussion

OSIs are uncommon ocular medical emergencies that require immediate medical attention, making it necessary for all healthcare providers to understand how to manage these cases.[1,4,9] As per the existing literature, the most common causes identified for OSI include misidentification for eyedrops by poorly sighted patients, and careless handling of superglue bottles by children and adults resulting in accidental splashing, thus causing ocular injury.[1,3,4,12,13] In our study, the most common predisposing risk factor for OSI was handling of the superglue in the absence of adult supervision in the pediatric cohort (92%) and careless handling of the glue bottles among the adults (91%). These risk factors were also found to be most prevalent in a one-year cross-sectional study published by McLean.[1] Similarly, in the results published by Tabatabaei et al., careless opening and working with superglues (78%) and a child’s curiosity without parents’ supervision (11%) were the most prevalent risk factors.[4] Leaving children unsupervised, either at home or while playing with glue bottles, and keeping these within their easy reach is a concerning issue and should be discouraged.[3,4] To prevent these injuries in children, it is important to store these bottles away from their reach preferably in locked cabinets. Advocating design changes of the bottles so as to child-proof the caps can help decrease the incidence of OSI. Child-proofing the caps of superglue bottles will also prevent injuries among careless adults who misidentify them as eyedrops or eye ointments and poorly sighted individuals, as opening these bottles will require more effort and scrutinization by an individual.[4]

The spectrum of ocular injuries caused by superglue includes dermatitis of the periocular skin, loss of eyelashes, chemical ankyloblepharon (abnormal fusion of the upper and the lower eyelid), severe ocular pain, conjunctival congestion, conjunctival and corneal abrasions, and punctate keratopathy.[1,4] Kate et al. reported a large series of patients with acute ocular burns and within this cohort, a subset experienced a mild severity superglue injury.[14] Reddy performed a literature review of all reports of patients with OSI and found that sticking of eyelids and eyelashes with an inability to open the eyes was the most common clinical presentation.[3] The superglue bonds only with the dry surfaces.[1] As soon as it falls into the eye, it causes severe burning and stinging sensation causing spontaneous closure of the eyelids, pushing the glue onto the relatively drier surfaces like the eyelid margin and the eyelashes, where it undergoes rapid polymerization, causing these surfaces to stick to each other. Due to its inherent chemical nature, glue induces severe inflammation, i.e. chemical conjunctivitis and keratitis on contact with the ocular surface. Alternatively, the retained glue inside the eye forms a cast and gets deposited in the lower conjunctival fornix causing mechanical keratopathy, especially involving the lower conjunctival and corneal surfaces. In our study, the common presenting signs were conjunctival congestion, polymerized glue stuck to the eyelids and eyelashes, and corneal epithelial defects. These signs may produce significant symptoms such as pain and photophobia which was reflected in the short duration from presentation to injury in our cases.

The two main principles involved in managing OSI include reversing the chemically induced tarsorrhaphy so that a thorough ocular evaluation can be performed and retained glue particles can be removed, as well as assessing the severity of ocular surface damage by staining the surface with fluorescein dye.[4] Immediate ocular irrigation delays glue condensation, chemical tarsorrhaphy, and the severity of ocular surface injury. Unfortunately, in our cohort, only 36% (10/28) of the pediatric eyes and 24% (9/38) of adult eyes received eye irrigation at the site of injury, thus resulting in a higher number of eyes with polymerized glue stuck to eyelids and eyelashes at presentation. Gentle pressure may be applied to separate the eyelids and perform a thorough ocular evaluation. Trimming of eyelashes may not be required in all cases.[3] Alternative methods to separate the eyelids have been reported previously using acetone (solvent for glue), margarine (high molecular weight oil), and sodium chloride 0.3% solution.[7,13,15] Acetone solution should be used with extreme caution, as it may cause chemical injury to the ocular surface. In our study, trimming of the eyelashes was required in a higher number of pediatric eyes as compared to adult eyes. This was mainly because children were uncooperative during examination for mechanical separation of eyelashes and hence trimming of eyelashes had to be performed under anesthesia. In our study, we prescribed ocular lubricants in all cases, topical antibiotics in all cases with corneal epithelial defects, and topical steroids in all cases with ocular surface inflammation for faster resolution of symptoms. Table 3 shows a descriptive analysis of studies where OSIs have been detailed in ≥5 eyes.

The risk of OSI can be reduced by implementing changes in the packaging of the superglue bottles and tubes, manufacturing products with a stronger pungent smell that could alert the user, implementing vertical ribs or braille on the bottle caps, especially for poorly sighted individuals, printing warnings in a bold print and emphasizing usage instructions in each country’s native language.[4] Another pressing issue is the general population’s unawareness of superglue applications and the need for immediate medical attention. The use of protective tools like gloves, masks, and face shields should be recommended while working with superglue. Children should always be supervised preferably while opening the bottle/tube, and application of the superglue should be performed by an adult. This is especially important to avoid these injuries in the pediatric population, as children may not cooperate for superglue removal, thus necessitating the use of general anesthesia for examination and removal of superglue. Immediate eye irrigation with clean water should be performed following ocular injury and forceful attempts to separate the eyelids and remove the glue from the eye should be avoided. Health education and safety strategies, which have traditionally targeted the workplace and sports complexes, should also target high-risk activities at schools and at home.

The strengths of this study are that we describe an uncommon form of ocular injury in a large cohort of patients comparing the injuries between adults and children. We also have described the mode of injury and the management of these injuries in our patient population. This may help us formulate preventive strategies against these injuries, thus preventing subsequent hospital visits in an emergency setting. The limitations of the study include its retrospective design.

OSIs represent a milder form of ocular injuries that resolve with medical management and are not a cause of long-term visual morbidity. Examination under anesthesia may be required in young children who may not cooperate for a thorough examination in the clinic. Modifications in the packaging of superglue bottles, supervised use of superglue by the children, and awareness among the general population that these substances could cause ocular injuries are vital for prevention.

References