Superstuck: A case of cyanoacrylate glue inside the eye of a pediatric patient

Cyanoacrylate-containing adhesives, commonly known as “superglue,” are commonplace and used in household tasks as well as for personal grooming purposes. While its rapid polymerization and stability have made it useful in the treatment of corneal perforations and purposeful temporary tarsorrhaphy, its removal after inadvertent instillation poses a common challenge for ophthalmologists. Many case reports of cyanoacrylate-related ocular injury exist in the literature, with most reporting inadvertent tarsorrhaphy, corneal abrasion, and conjunctivitis [1],[2]. These injuries can occur quickly following exposure to this class of adhesives, precisely due to their rapid polymerization and hardening once applied. Once the glue hardens inside the eye, any rubbing motion which occurs while the patient attempts to remove it can cause corneal or conjunctival injury. While most patients with these injuries in the adult literature had excellent outcomes [2], inadvertent glue tarsorrhaphy in young children poses risk of amblyopia if not addressed quickly. We describe a minimally traumatic technique, “unzipping,” to remove adhesive in a young child.

An otherwise healthy 7-year-old girl presented about 10 hours after inadvertently splashing artificial nail glue into her left eye. She had been trying to apply her own false nails when she accidentally flicked a large amount of glue into her eye. Her mother immediately tried to rinse the eye with water to remove glue but could not get the eye open. The child’s mother also tried to loosen the glue with warm water and to remove it from her eyelashes with a small amount of acetone but was unable to make any progress. The child also became progressively more frightened with repeated attempts at removal, so her mother brought her to the emergency room to be evaluated.

On initial exam, the right eye was normal, with normal fix and follow vision, intraocular pressure, and anterior segment exam. The left upper and lower eyelids were completely stuck together (Figure 1A), and the child was not amenable to any attempted examination maneuvers, even with copious distraction and reassurance. Shared decision-making between the anesthesiology and ophthalmology teams and the patient’s parents led to the choice to put the child under general anesthesia to facilitate safe removal of the glue and thorough examination. Once the patient was under anesthesia, the medial two-thirds of the lids were noted to be completely fused by glue, with a small gap laterally appreciable when traction was applied. Sterile mineral oil was applied to the lashes to soften and lubricate the area glued together. Gentle traction in an unzipping motion (Figure 1B) was applied using cotton-tipped applicators from medial to lateral canthus. Though some lashes were epilated, the lids were otherwise traumatically separated. A lid speculum and corneal shield with lubricant were placed, followed by meticulous removal of remaining glue from the upper and lower lashes (Figure 1C). Some large pieces of glue required crushing with mosquito forceps, followed by removal with toothed forceps. At the conclusion of the case, the lids were separated without margin injury, the corneal epithelium was intact, intraocular pressure was normal, and the anterior and posterior segment exams were normal in both eyes (Figure 1D).

Most reported cases of superglue injury to the eye occur due to patient inadvertent instillation of glue rather than ophthalmic medication or drop into the eye, or, as in this case, lack of parental supervision while children play with the common household items that contain cyanoacrylate (including false lash glue, false nail glue, craft glue). The resemblance of cyanoacrylate glue containers to eyedrop containers has been noted by multiple authors [2],[3],[4] and poses a public health concern; glue manufacturers should be urged to put child-proof caps on bottles, and to manufacture them to be easily distinguished from eyedrop bottles. In the home, parents should keep cyanoacrylate-containing containers out of reach of children and supervise them closely should they be allowed to use these materials.

In children younger than 8, removal of cyanoacrylate from the eye should be accomplished as soon as possible to reduce the likelihood of amblyopia. Children may require general anesthesia to allow for safe examination and removal of glue. Removal has two main goals: atraumatic separation of the lids, and timely diagnosis and treatment of any chemical or physical damage to the conjunctiva or corneal epithelium. While acetone can easily dissolve cyanoacrylate, it is not safe for the ocular surface; thus, an ophthalmic formulation of lubricant, such as mineral oil or petrolatum, can be used to loosen the adhesion of glue to tissue.

Pediatric ophthalmic injury due to cyanoacrylate glue should be examined and glue removed from the eye in a timely fashion. Parents should be encouraged to keep children away from cyanoacrylate-containing household items.

Traumatic ocular injury due to cyanoacrylate glue exposure is a common mechanism for eye injury in children. In cases with inadvertent glue tarsorrhaphy, this injury poses risk of amblyopia and requires prompt treatment. We describe an atraumatic method of treating this injury via an “unzipping” technique.