Original Investigation
Use of Cyanoacrylate Glue for Temporary Tarsorrhaphy in Children Dipti Trivedi, M.B.BCh., M.R.C.OPhth.*, Maureen McCalla, R.N.*, Zoe Squires, G.C.S.E.†, and Manoj Parulekar, M.S., F.R.C.S., F.R.C.OPhth.* *Birmingham Children’s Hospital, Steelhouse Lane; and †The National Artificial Eye Service, Birmingham, United Kingdom
Purpose: Congenital anophthalmia and postenucleation socket contracture are difficult conditions that require serial socket expansion with the use of hydrogel expanders and custom-made conformers along with temporary tarsorrhaphy. Methods: The authors undertook a part prospective case review of all children undergoing temporary tarsorrhaphy using cyanoacrylate glue over a 3-year period at a tertiary specialist children’s hospital. Results: They report a series of 7 children undergoing temporary tarsorrhaphy with cyanoacrylate glue instead of the conventional suturing technique. Indications were socket expansion (n = 4), fornix deepening (n = 2), prosthesis reposition, and prolapsed conjunctiva following enucleation (n = 1).The age range was 3 weeks to 14 years (mean, 2.7 years). The glue tarsorrhaphy lasted between 0.5 and 13 weeks (mean, 4.5 weeks). There were no adverse outcomes, and the glue tarsorrhaphy was tolerated well in all cases, with relative ease of reapplication of glue in clinic. Conclusions: Their study demonstrates that this technique allows quick and efficient temporary tarsorrhaphy with relative ease of reapplication in a clinic setting, avoiding the need for multiple general anesthetics. (Ophthal Plast Reconstr Surg 2014;30:60–63)
Congenital anophthalmia and postenucleation socket contracture are difficult conditions with severe soft tissue deficiency and often require serial socket expansion with the use of hydrogel expanders and/or progressively larger custom-made conformers. The hydrophilic hemispheric implant is sutured in the anophthalmic conjunctival socket and expands over days by absorbing water from tears. This is usually combined with temporary suture tarsorrhaphy to allow expansion in the required direction by creating a closed space.13–15 Suture tarsorrhaphy is very effective as a temporary procedure, but infection of the suture track, granuloma, loss of eyelashes, permanent scarring from the suture entry and exit points, and bleeding are recognized complications of this technique. Cyanoacrylate glue has previously been used for ocular pathologic study.16,17 There have been some isolated reports of using cyanoacrylate glue as an alternative to suture tarsorrhaphy for socket expansion,18 but there is very little literature on the subject. The authors report their experience of using temporary glue tarsorrhaphy for socket expansion on 7 children and discuss limitations and benefits, with recommendations for readers wishing to use this technique.
METHODS
M
Setting. We undertook a part prospective case review of all children undergoing temporary tarsorrhaphy using cyanoacrylate glue over a 3-year period between January 2010 and January 2013 at a tertiary specialist children’s hospital. The study was approved by the institutional audit committee.
Accepted for publication August 21, 2013. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Manoj Parulekar, M.S., F.R.C.S., F.R.C.OPhth., Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom. E-mail: [email protected] DOI: IOP.0000000000000011
Technique. The cyanoacrylate glue used in this series was provided in a prefilled squeezable applicator, ready to use (LiquiBand Optima or LiquiBand Standard; Advanced Medical Solutions Group, Cheshire, United Kingdom). The tip of the nozzle is cut off, and the glue squeezed out of the reservoir while holding the eyelid margins in close apposition, approximately 0.5 mm apart. This allows sufficient space for the glue to enter the space between the eyelid margins and form a bond between the 2 eyelids. Liquid glue of 0.1 to 0.2 ml is sufficient for most cases. The eyelids are then held together for up to 1 minute until the glue sets—usually evident by visible opacification. Additional glue placed onto this bond will increase the duration of action of the glue tarsorrhaphy. Some of the glue will inevitably find its way in the socket and adhere to the underlying prosthesis or expander but will separate spontaneously in a few weeks (Fig. 1). Any residual adherent glue can be scraped or picked off the prosthesis with a pair of forceps. The outer third of the eyelid margins was glued together for cases such as prosthesis repositioning or two-thirds or more for most cases of socket expansion. The eyelashes are inevitably glued together in the process, and it is not unusual to lose a few eyelashes that will grow back in due course.
ost growth of the eye and orbit occurs in the first few years of life. Evidence from animal experiments1–3 and observation of human subjects4,5 suggest that the presence of an eyelid promotes normal development of the bony orbit. Congenital absence of the eye or loss of the eye in early life will result in severe volume deficiency and impact on orbital growth.5–7 It therefore follows that timely restoration of the lost volume should promote near-normal orbital growth in such cases. In anophthalmic sockets, it has been shown that the implanted orbital volume has a positive correlation with socket enlargement, with better results associated with expanding orbital implants compared with the rigid spheres that require serial exchanges.8–11 Similarly, with acquired anophthalmia following childhood enucleation, it is a standard practice to replace the lost volume with rigid orbital implants to improve cosmesis and promote orbital growth.12
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Ophthal Plast Reconstr Surg, Vol. 30, No. 1, 2014
Ophthal Plast Reconstr Surg, Vol. 30, No. 1, 2014
Temporary Glue Tarsorrhaphy
FIG. 1. Socket expander in situ.
FIG. 2. Artificial eye placed over socket expander.
Trimming the eyelashes might reduce the risk of losing eyelashes in this process and may also reduce the duration of efficacy of the tarsorrhaphy. The eyelashes were left untrimmed in this series as they provide an additional surface for the glue to bond and hold the eyelids together. The technique of glue application in the outpatient setting is similar to the above. Unlike surgical tarsorrhaphy for other indications, the authors aim for a central or lateral glue tarsorrhaphy to cover approximately 75% of the eyelid margin, allowing opening in the palpebral fissure at either end to permit the discharge of conjunctival secretions.
between successive glue applications ranged from 1 to 12 weeks. Two patients undergoing glue tarsorrhaphy to aid retention of the prosthesis (one was for postenucleation conjunctival prolapse, and the other was to stretch the fornix) required only the initial application. Many parents reported a tendency for the child to attempt manual removal of glue by picking at the eyelids. Two such cases had adequate eyelid closure but required additional glue due to parental anxiety. One of these patients required 18 episodes of glue application over a 2-year period of serial socket expansion. The number of glue applications between successive socket expansion procedures ranged from 1 to 2 (mean, 1.2). There were 21 reapplications of glue in theater under GA but all in conjunction with a surgical procedure. Eighteen of these underwent hydrogel expander replacement with glue tarsorrhaphy, 1 required lateral canthotomy, 1 had artificial eye replacement, and 1 required an additional eyelid suture (Fig. 2). One case had premature separation of the eyelids and loss of prosthetic shell on 2 occasions. This was replaced in the outpatient setting and glue reapplied. There was also 1 episode of the expander falling out prematurely, reported to be secondary to the child picking at the glue, which required replacement in theater under GA. One child required additional suture to the eyelid to obtain adequate eyelid closure. There were no adverse outcomes, and all tolerated the glue well, with relative ease of reapplication of glue in clinic if no additional procedure was required. The parents of 1 child who repeatedly manually removed the glue were taught how to reapply the glue if necessary and did so on several occasions, demonstrating its relative ease of application.
Data Collection. Apart from demographic data, specific attention was paid to the underlying diagnosis, indication for treatment, previous procedures if any, age at first glue application, number and timing of reapplication of glue, procedure setting, and complications. Parents were asked to inform the clinic if the eyelids had separated prior to the next scheduled clinic visit. If they did not report premature eyelid separation, the time to the first postoperative visit was taken as the length of time the glue had lasted. Subsequent glue applications were recorded as episodes of regluing, and intervals between applications were recorded. Any additional procedures undertaken were documented. We also noted whether the glue was applied in an outpatient setting or operating theater, if it was in conjunction with any other procedures, and whether a general anesthetic (GA) was necessary. Any eyelid inflammation, eyelid margin changes, or loss of eyelashes were recorded. Other information recorded that was difficult to quantify included parental observations on eyelid inflammation, any discharge from the eyelids or socket, how well the child tolerated the procedure if performed in outpatient setting or at home, and any attempts by the child to remove the glue.
RESULTS Seven cases undergoing cyanoacrylate glue tarsorrhaphy technique between January 2010 and January 2013 were identified and included in this series. The underlying diagnosis was postenucleation socket following retinoblastoma (n = 3), anophthalmia (n = 3), and post exenteration socket following medulloepithelioma (n = 1). The age range was 3 weeks to 14 years (mean, 2.7 years; median, 6 months). Indications for glue tarsorrhaphy were in conjunction with socket expansion (n = 4), to retain an oversized conformer for forniceal lengthening (n = 2) and to reposition the prosthesis and prolapsed conjunctiva following enucleation (n = 1). The duration to first post glue tarsorrhaphy visit ranged from 2.5 to 11 weeks (mean, 4.5 weeks). Subsequent visits ranged from 0.5 to 13 weeks (mean, 4 weeks; median, 3.5 weeks). In this cohort of 7 cases, there were a total of 33 episodes of reapplication of glue. Duration
DISCUSSION Apart from the visual impairment and systemic associations, anophthalmic children and their parents are often faced with psychosocial problems due to the resulting cosmetic appearance.14 Early initiation of socket management is paramount to maximize orbital volume, for the development of conjunctival fornices, and for facial symmetry to allow for the best possible cosmetic outcome.13–15 The normal eye at birth is typically 70% of its adult size compared with the face, which is
Use of Cyanoacrylate Glue for Temporary Tarsorrhaphy in Children Dipti Trivedi, M.B.BCh., M.R.C.OPhth.*, Maureen McCalla, R.N.*, Zoe Squires, G.C.S.E.†, and Manoj Parulekar, M.S., F.R.C.S., F.R.C.OPhth.* *Birmingham Children’s Hospital, Steelhouse Lane; and †The National Artificial Eye Service, Birmingham, United Kingdom
Purpose: Congenital anophthalmia and postenucleation socket contracture are difficult conditions that require serial socket expansion with the use of hydrogel expanders and custom-made conformers along with temporary tarsorrhaphy. Methods: The authors undertook a part prospective case review of all children undergoing temporary tarsorrhaphy using cyanoacrylate glue over a 3-year period at a tertiary specialist children’s hospital. Results: They report a series of 7 children undergoing temporary tarsorrhaphy with cyanoacrylate glue instead of the conventional suturing technique. Indications were socket expansion (n = 4), fornix deepening (n = 2), prosthesis reposition, and prolapsed conjunctiva following enucleation (n = 1).The age range was 3 weeks to 14 years (mean, 2.7 years). The glue tarsorrhaphy lasted between 0.5 and 13 weeks (mean, 4.5 weeks). There were no adverse outcomes, and the glue tarsorrhaphy was tolerated well in all cases, with relative ease of reapplication of glue in clinic. Conclusions: Their study demonstrates that this technique allows quick and efficient temporary tarsorrhaphy with relative ease of reapplication in a clinic setting, avoiding the need for multiple general anesthetics. (Ophthal Plast Reconstr Surg 2014;30:60–63)
Congenital anophthalmia and postenucleation socket contracture are difficult conditions with severe soft tissue deficiency and often require serial socket expansion with the use of hydrogel expanders and/or progressively larger custom-made conformers. The hydrophilic hemispheric implant is sutured in the anophthalmic conjunctival socket and expands over days by absorbing water from tears. This is usually combined with temporary suture tarsorrhaphy to allow expansion in the required direction by creating a closed space.13–15 Suture tarsorrhaphy is very effective as a temporary procedure, but infection of the suture track, granuloma, loss of eyelashes, permanent scarring from the suture entry and exit points, and bleeding are recognized complications of this technique. Cyanoacrylate glue has previously been used for ocular pathologic study.16,17 There have been some isolated reports of using cyanoacrylate glue as an alternative to suture tarsorrhaphy for socket expansion,18 but there is very little literature on the subject. The authors report their experience of using temporary glue tarsorrhaphy for socket expansion on 7 children and discuss limitations and benefits, with recommendations for readers wishing to use this technique.
METHODS
M
Setting. We undertook a part prospective case review of all children undergoing temporary tarsorrhaphy using cyanoacrylate glue over a 3-year period between January 2010 and January 2013 at a tertiary specialist children’s hospital. The study was approved by the institutional audit committee.
Accepted for publication August 21, 2013. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Manoj Parulekar, M.S., F.R.C.S., F.R.C.OPhth., Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom. E-mail: [email protected] DOI: IOP.0000000000000011
Technique. The cyanoacrylate glue used in this series was provided in a prefilled squeezable applicator, ready to use (LiquiBand Optima or LiquiBand Standard; Advanced Medical Solutions Group, Cheshire, United Kingdom). The tip of the nozzle is cut off, and the glue squeezed out of the reservoir while holding the eyelid margins in close apposition, approximately 0.5 mm apart. This allows sufficient space for the glue to enter the space between the eyelid margins and form a bond between the 2 eyelids. Liquid glue of 0.1 to 0.2 ml is sufficient for most cases. The eyelids are then held together for up to 1 minute until the glue sets—usually evident by visible opacification. Additional glue placed onto this bond will increase the duration of action of the glue tarsorrhaphy. Some of the glue will inevitably find its way in the socket and adhere to the underlying prosthesis or expander but will separate spontaneously in a few weeks (Fig. 1). Any residual adherent glue can be scraped or picked off the prosthesis with a pair of forceps. The outer third of the eyelid margins was glued together for cases such as prosthesis repositioning or two-thirds or more for most cases of socket expansion. The eyelashes are inevitably glued together in the process, and it is not unusual to lose a few eyelashes that will grow back in due course.
ost growth of the eye and orbit occurs in the first few years of life. Evidence from animal experiments1–3 and observation of human subjects4,5 suggest that the presence of an eyelid promotes normal development of the bony orbit. Congenital absence of the eye or loss of the eye in early life will result in severe volume deficiency and impact on orbital growth.5–7 It therefore follows that timely restoration of the lost volume should promote near-normal orbital growth in such cases. In anophthalmic sockets, it has been shown that the implanted orbital volume has a positive correlation with socket enlargement, with better results associated with expanding orbital implants compared with the rigid spheres that require serial exchanges.8–11 Similarly, with acquired anophthalmia following childhood enucleation, it is a standard practice to replace the lost volume with rigid orbital implants to improve cosmesis and promote orbital growth.12
60
Ophthal Plast Reconstr Surg, Vol. 30, No. 1, 2014
Ophthal Plast Reconstr Surg, Vol. 30, No. 1, 2014
Temporary Glue Tarsorrhaphy
FIG. 1. Socket expander in situ.
FIG. 2. Artificial eye placed over socket expander.
Trimming the eyelashes might reduce the risk of losing eyelashes in this process and may also reduce the duration of efficacy of the tarsorrhaphy. The eyelashes were left untrimmed in this series as they provide an additional surface for the glue to bond and hold the eyelids together. The technique of glue application in the outpatient setting is similar to the above. Unlike surgical tarsorrhaphy for other indications, the authors aim for a central or lateral glue tarsorrhaphy to cover approximately 75% of the eyelid margin, allowing opening in the palpebral fissure at either end to permit the discharge of conjunctival secretions.
between successive glue applications ranged from 1 to 12 weeks. Two patients undergoing glue tarsorrhaphy to aid retention of the prosthesis (one was for postenucleation conjunctival prolapse, and the other was to stretch the fornix) required only the initial application. Many parents reported a tendency for the child to attempt manual removal of glue by picking at the eyelids. Two such cases had adequate eyelid closure but required additional glue due to parental anxiety. One of these patients required 18 episodes of glue application over a 2-year period of serial socket expansion. The number of glue applications between successive socket expansion procedures ranged from 1 to 2 (mean, 1.2). There were 21 reapplications of glue in theater under GA but all in conjunction with a surgical procedure. Eighteen of these underwent hydrogel expander replacement with glue tarsorrhaphy, 1 required lateral canthotomy, 1 had artificial eye replacement, and 1 required an additional eyelid suture (Fig. 2). One case had premature separation of the eyelids and loss of prosthetic shell on 2 occasions. This was replaced in the outpatient setting and glue reapplied. There was also 1 episode of the expander falling out prematurely, reported to be secondary to the child picking at the glue, which required replacement in theater under GA. One child required additional suture to the eyelid to obtain adequate eyelid closure. There were no adverse outcomes, and all tolerated the glue well, with relative ease of reapplication of glue in clinic if no additional procedure was required. The parents of 1 child who repeatedly manually removed the glue were taught how to reapply the glue if necessary and did so on several occasions, demonstrating its relative ease of application.
Data Collection. Apart from demographic data, specific attention was paid to the underlying diagnosis, indication for treatment, previous procedures if any, age at first glue application, number and timing of reapplication of glue, procedure setting, and complications. Parents were asked to inform the clinic if the eyelids had separated prior to the next scheduled clinic visit. If they did not report premature eyelid separation, the time to the first postoperative visit was taken as the length of time the glue had lasted. Subsequent glue applications were recorded as episodes of regluing, and intervals between applications were recorded. Any additional procedures undertaken were documented. We also noted whether the glue was applied in an outpatient setting or operating theater, if it was in conjunction with any other procedures, and whether a general anesthetic (GA) was necessary. Any eyelid inflammation, eyelid margin changes, or loss of eyelashes were recorded. Other information recorded that was difficult to quantify included parental observations on eyelid inflammation, any discharge from the eyelids or socket, how well the child tolerated the procedure if performed in outpatient setting or at home, and any attempts by the child to remove the glue.
RESULTS Seven cases undergoing cyanoacrylate glue tarsorrhaphy technique between January 2010 and January 2013 were identified and included in this series. The underlying diagnosis was postenucleation socket following retinoblastoma (n = 3), anophthalmia (n = 3), and post exenteration socket following medulloepithelioma (n = 1). The age range was 3 weeks to 14 years (mean, 2.7 years; median, 6 months). Indications for glue tarsorrhaphy were in conjunction with socket expansion (n = 4), to retain an oversized conformer for forniceal lengthening (n = 2) and to reposition the prosthesis and prolapsed conjunctiva following enucleation (n = 1). The duration to first post glue tarsorrhaphy visit ranged from 2.5 to 11 weeks (mean, 4.5 weeks). Subsequent visits ranged from 0.5 to 13 weeks (mean, 4 weeks; median, 3.5 weeks). In this cohort of 7 cases, there were a total of 33 episodes of reapplication of glue. Duration
DISCUSSION Apart from the visual impairment and systemic associations, anophthalmic children and their parents are often faced with psychosocial problems due to the resulting cosmetic appearance.14 Early initiation of socket management is paramount to maximize orbital volume, for the development of conjunctival fornices, and for facial symmetry to allow for the best possible cosmetic outcome.13–15 The normal eye at birth is typically 70% of its adult size compared with the face, which is
