This video, using a simulation eye in a wet lab, demonstrates the preparation and techniques required to perform a corneal glue procedure on a small corneal perforation.
Corneal perforation is a sight threatening complication with numerous causes including inflammation, infection and trauma. Key principles of management include swift recognition, treatment of the cause and implementing the appropriate intervention to promote healing. A diagnosis of corneal perforation is usually unambiguous with a constellation of clinical features including: an overt perforation site; corneal thinning; Seidel’s positive sign (aqueous leakage); iris pigment in the wound and shallowing of the anterior chamber. Robert Webster et al. published a case report in 1968 describing the use of cyanoacrylate glue adhesive in two corneal perforations with favorable outcomes. There have been changes to corneal glue technique since, but the basic principle remains in that the adhesive acts as a temporary tamponade to allow and promote natural healing of the defect. Every perforation requires individualised care – one must treat the cause of the perforation as well as considering the patient’s comorbidities.
Corneal glue is an effective intervention for small corneal perforations, usually 2mm or less in size. At all times during management other surgical options must be considered, such as conjunctival flaps, amniotic membrane or corneal grafts (patch or full penetrating keratoplasty)
Corneal perforations that are greater than 2-3mm in size or if the patient is unable to tolerate the procedure and aftercare safely are relative contraindications.
• Preferably the patient is treated in theatre, a clean room or if appropriate, at the slit lamp. • First prepare your equipment and have the following opened at the ready on a sterile field: cyanoacrylate glue, chloramphenicol ointment, gallipot, 3mm punch biopsy, lid drape, bandage contact lens (BCL) and spears. • Instill topical anaesthesia – sub-tenon and sub-conjunctival anaesthesia can deform limbal profile, effecting the placement of a BCL. • Carefully place a lid speculum, taking care to not exert any downward pressure on the globe. • Identify the perforation site, then clean and debride the epithelium around the site with a scalpel and forceps - this improves glue adherence. • Dry perforation site with the spears. • Lay the lid drape over the gallipot and punch out a plastic disc using the biopsy. You can use corneal forceps to retrieve discs from the punch. • A small amount of glue is applied on top of your gallipot – dab 3x spots of glue to ensure one spot is the right amount. • Using the plastic tip of the spear, first dab chloramphenicol ointment, then pick up a 3mm plastic disc, then dab disc in a small amount of the glue. • The glue does begin to dry so moving efficiently but safely is essential. • Carefully place glue with disc over the perforation site, ensuring the whole perforation is covered and allow the glue to polymerise and dry. • Once dry, carefully place the BCL over the cornea using the forceps. BCLs improve comfort and reduce the risk of the adhesive dislodging. • Remove the speculum, again taking care to not exert any downward pressure on the globe. • The procedure is complete.
Maximising gluing success means optimising appropriate treatments for the cause of the perforation.
A diagnosis of corneal perforation is usually unmistakable with a constellation of clinical features including: an overt perforation site; corneal thinning; Seidel’s positive sign (aqueous leakage); iris pigment in the wound and shallowing of the anterior chamber.
Corneal glue is a relatively simple and quick procedure rarely resulting in significant side effects or complications. Glue can be easily employed before more invasive surgical procedures. Post-procedure aftercare requires patient cooperation and frequent clinic review which can be a challenge.
Failure for the perforation to close, necessitating other interventions. Corneal infection and abscess formation.
The author declares no conflict of interest.
1. Webster Jr. RG, Slansky HH, Refojo MF. Arch Ophthalmol. (1968) The Use of Adhesive for the Closure of Corneal Perforations; 80 (6): 705-709. 2. Weiner G, Dhaliwal DK, Karp CL, Tu EY, Tuli SS. American Association of Ophthalmology, EyeNet Magazine. (2016) Corneal Perforations.