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Getting Hooked: A Simple Technique for the Treatment of Adhesive Injuries to the Eyelids
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2016 Ó 2016 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2016.09.013
Techniques and Procedures GETTING HOOKED: A SIMPLE TECHNIQUE FOR THE TREATMENT OF ADHESIVE INJURIES TO THE EYELIDS Kristen Jijelava, MD,* Hongvan Le, MD,* Jack Parker, MD,*† and Jeffrey Yee, MS, MD* *UAB Callahan Eye Hospital, Birmingham, Alabama and †Parker Cornea, Birmingham, Alabama Reprint Address: Jeffrey Yee, MS, MD, UAB Callahan Eye Hospital, Birmingham, Alabama
, Abstract—Background: Ocular chemical injuries due to accidental exposure or application of cyanoacrylate, commonly known as ‘‘superglue,’’ have increased over the past 30 years. However, current treatment options to relieve eyelid adhesions due to cyanoacrylate applications are difficult to successfully execute and can require sedation or general anesthesia. Here we describe a simple technique to release eyelid adhesions due to cyanoacrylate, or other adhesive agents, that can be successfully performed at bedside without sedation. Discussion: Topical anesthetic is instilled in the involved eye through an opening identified in the lid fissure. A Jameson muscle hook is inserted through the opening with the distal element of the hook normal to the surface of the eye. The hook is then pulled parallel to the lid margins and through the site of adhesion while counter pressure is applied with the fellow hand in the opposite motion of the hook. Residual glue from the eyelashes can be trimmed with blunt-tip scissors. Examination of the eyelids and ocular surface after application of the technique to open the eyelids showed successful release of adhesion sites with no additional injuries to the eye itself. Conclusions: A Jameson muscle hook can be used in emergency departments to safely and successfully relieve eyelid adhesions due to the inadvertent application of cyanoacrylate glue without the use of general anesthesia. Ó 2016 Elsevier Inc. All rights reserved.
INTRODUCTION Inadvertent exposure to cyanoacrylate adhesive, commonly known as superglue, is a common cause of ocular chemical injury. While cyanoacrylate first became commercially available nearly 60 years ago, it was not until the early 1980s when case reports of cyanoacrylate eye injuries started to be reported in the literature (1,2). This increase in incidence corresponds to a change in the packaging of superglue to resemble ophthalmic medication eyedropper bottles. Since then, reports of accidental application of cyanoacrylate to the eye and eyelids have been reported due to mistaking the superglue bottle for prescribed ophthalmic drops, being splashed by the glue when uncapping the bottle, inadvertent nail glue application, and frequently by curious children playing with the superglue bottles (3). Multiple methods for treating the superglue tarsorrhaphy that results from application of superglue to the eyelid margins have been described, however, these methods can be difficult to execute and have frequently required sedation or general anesthesia in pediatric patients (2–6). Here we describe a simple and effective technique to reverse eyelid adhesion that can be performed in emergency departments without the use of harmful chemicals or need for general anesthesia.
, Keywords—cyanoacrylate; eye injury; eyelids; superglue; tarsorrhaphy
RECEIVED: 30 August 2016; ACCEPTED: 2 September 2016 1
2
K. Jijelava et al.
TECHNIQUE The technique requires only the use of a topical anesthetic, such as topical tetracaine 0.5% or proparacaine 0.5%, and a Jameson muscle hook (Ambler Surgical, Exton, PA; Rhein Medical, St. Petersburg, FL). The topical anesthetic is readily available in most emergency departments and clinics. A muscle hook is a reusable instrument that can be procured at an affordable price from ophthalmic instrument vendors and catalogs. To perform the procedure, first carefully examine the adherent eyelid margin and assess for any gap in the lid fissure by manually applying opposite vector forces along the eyelid margin (Figure 1). Once an opening is identified, a drop of topical anesthetic is instilled into the eye through the opening. If a gap is present, all attempts to visually inspect the eye through the fissure are made. The blunt end of a Jameson muscle hook is then inserted through the identified opening, and the hook is rotated so that the distal element of the hook is normal to the surface of the eye (Figure 2). Next, the hook is pulled through the site of the eyelid adhesion by pulling the hook simultaneous parallel to the lid margins and slightly upward and away from the surface of the eye so that it minimizes any contact between the bulb of the hook and the eye. Counter pressure in the opposite direction of the muscle hook can be applied with the fellow hand. When all the sites of adhesion have been released and the eye is fully opened, residual glue from the eyelashes or around the eyelid can be carefully trimmed with blunt-tip scissors. The remaining glue will slough off over the course of the next several days (7). DISCUSSION Cyanoacrylate glue is a widely available adhesive commonly found in households; it is a monomer of cyanoacetate and formaldehyde, which polymerizes within seconds on dry surfaces, such as eyelid margins. Ophthalmic exposure can result in conjunctival abrasion, chemical conjunctivitis, corneal abrasion, keratitis, or eyelid adhesions (5). When exposure to the ocular surfaces occurs, the immediate response tends to be forceful
Figure 1. Illustration demonstrating technique to relieve eyelid adhesions. (A) Carefully examine the eyelids and manually apply opposite vector forces along the eyelid
margin to identify any opening in the lid fissure. (B) Instill a drop of topical anesthetic through the opening in the lid fissure. (C) Insert the blunt end of a Jameson muscle hook through the identified opening and rotate the hook so that the distal element of the hook is normal to the surface of the eye. (D) Pull the hook parallel to the lid margins and through the site of the eyelid adhesion. Counter pressure in the opposite direction of the muscle hook can be applied with the fellow hand. (E) Re-examine the eyelids to ensure all adhesion sites are cleaved and the eye is fully opened. Residual glue from the eyelashes or around the eyelid can be carefully trimmed with blunt-tip scissors.
Opening Superglued Lids
3
patients, for whom cooperation with lash trimming can be difficult, and for whom observation alone is frequently unwanted by families, uncomfortable for patients, and unacceptable to physicians desiring to evaluate the ocular surface for further injury. This technique may have several advantages over others described, including ease and simplicity, avoidance of caustic agents (i.e., acetone) adjacent to the ocular surface, and the absence of a requirement for general anesthesia. This technique has been used in our resident ophthalmology clinic, Children’s of Alabama, and at the Callahan Eye Hospital for >10 years without complication and has been successful in releasing all cases of chemical adhesion-induced tarsorrhaphy. CONCLUSIONS
Figure 2. (A) Child with adhesion of right upper and lower eyelids secondary to accidental cyanoacrylate application. (B) Placement of Jameson muscle hook being pulled parallel to lid margin to relieve adhesion. (C) Child with relief of eyelid adhesion after executing the technique described.
The technique described in this article is a simple, effective, and safe treatment option for both pediatric and adult patients with cyanoacrylate-induced adhesion of eyelids, who often first present to their local emergency department for treatment. This method, which does not involve placing any sharp instruments near the eye, has been used successfully by physicians at the University of Alabama at Birmingham Hospital and affiliated locations without complication.
REFERENCES closing of the eyelids due to a sensation of burning that effectively results in a chemical tarsorrhaphy. The incidence of ocular injury due to cyanoacrylate adhesive is not known and varies widely from 53 cases (25% of which were children) reported in the literature in the preceding 30 years up to the time of publication of Reddy, 2012 as compared with a reported 105 cases in just a 3-month time period at Farabi Eye Hospital (5,6). Management strategies in the literature vary from observation, to attempted manual forceful opening, to chemical dissolution (e.g., with acetone), to administration of general anesthesia followed by lash trimming in the operating room. This latter option has been the procedure of choice for especially young
1. Margo CE, Trobe JD. Tarsorrhaphy from accidental instillation of cyanoacrylate adhesive in the eye. JAMA 1982;247:660–1. 2. Yusuf IH, Patel CK. A sticky sight: cyanoacrylate ‘‘superglue’’ injuries of the eye. BMJ Case Rep 2010;2010. 3. McLean CJ. Ocular superglue injury. J Accid Emerg Med 1997;14: 40–1. 4. Good AM, McCabe SE. Superglue accidents and the eye—causes and prevention. Br J Ophthalmol 1994;78:802. 5. Reddy SC. Superglue injuries of the eye. Int J Ophthalmol 2012;5: 634–7. 6. Tabatabaei SA, Modanloo S, Ghiyasvand AM, et al. Epidemiological aspects of ocular superglue injuries. Int J Ophthalmol 2016;9: 278–81. 7. Yee J, Austin T. Getting out of a sticky situation. Review of Ophthalmology. Available at: http://www.reviewofophthalmology.com/ content/d/features/i/1326/c/25457/. Published October 28, 2004. Accessed June 25, 2016.
http://dx.doi.org/10.1016/j.jemermed.2016.09.013
Techniques and Procedures GETTING HOOKED: A SIMPLE TECHNIQUE FOR THE TREATMENT OF ADHESIVE INJURIES TO THE EYELIDS Kristen Jijelava, MD,* Hongvan Le, MD,* Jack Parker, MD,*† and Jeffrey Yee, MS, MD* *UAB Callahan Eye Hospital, Birmingham, Alabama and †Parker Cornea, Birmingham, Alabama Reprint Address: Jeffrey Yee, MS, MD, UAB Callahan Eye Hospital, Birmingham, Alabama
, Abstract—Background: Ocular chemical injuries due to accidental exposure or application of cyanoacrylate, commonly known as ‘‘superglue,’’ have increased over the past 30 years. However, current treatment options to relieve eyelid adhesions due to cyanoacrylate applications are difficult to successfully execute and can require sedation or general anesthesia. Here we describe a simple technique to release eyelid adhesions due to cyanoacrylate, or other adhesive agents, that can be successfully performed at bedside without sedation. Discussion: Topical anesthetic is instilled in the involved eye through an opening identified in the lid fissure. A Jameson muscle hook is inserted through the opening with the distal element of the hook normal to the surface of the eye. The hook is then pulled parallel to the lid margins and through the site of adhesion while counter pressure is applied with the fellow hand in the opposite motion of the hook. Residual glue from the eyelashes can be trimmed with blunt-tip scissors. Examination of the eyelids and ocular surface after application of the technique to open the eyelids showed successful release of adhesion sites with no additional injuries to the eye itself. Conclusions: A Jameson muscle hook can be used in emergency departments to safely and successfully relieve eyelid adhesions due to the inadvertent application of cyanoacrylate glue without the use of general anesthesia. Ó 2016 Elsevier Inc. All rights reserved.
INTRODUCTION Inadvertent exposure to cyanoacrylate adhesive, commonly known as superglue, is a common cause of ocular chemical injury. While cyanoacrylate first became commercially available nearly 60 years ago, it was not until the early 1980s when case reports of cyanoacrylate eye injuries started to be reported in the literature (1,2). This increase in incidence corresponds to a change in the packaging of superglue to resemble ophthalmic medication eyedropper bottles. Since then, reports of accidental application of cyanoacrylate to the eye and eyelids have been reported due to mistaking the superglue bottle for prescribed ophthalmic drops, being splashed by the glue when uncapping the bottle, inadvertent nail glue application, and frequently by curious children playing with the superglue bottles (3). Multiple methods for treating the superglue tarsorrhaphy that results from application of superglue to the eyelid margins have been described, however, these methods can be difficult to execute and have frequently required sedation or general anesthesia in pediatric patients (2–6). Here we describe a simple and effective technique to reverse eyelid adhesion that can be performed in emergency departments without the use of harmful chemicals or need for general anesthesia.
, Keywords—cyanoacrylate; eye injury; eyelids; superglue; tarsorrhaphy
RECEIVED: 30 August 2016; ACCEPTED: 2 September 2016 1
2
K. Jijelava et al.
TECHNIQUE The technique requires only the use of a topical anesthetic, such as topical tetracaine 0.5% or proparacaine 0.5%, and a Jameson muscle hook (Ambler Surgical, Exton, PA; Rhein Medical, St. Petersburg, FL). The topical anesthetic is readily available in most emergency departments and clinics. A muscle hook is a reusable instrument that can be procured at an affordable price from ophthalmic instrument vendors and catalogs. To perform the procedure, first carefully examine the adherent eyelid margin and assess for any gap in the lid fissure by manually applying opposite vector forces along the eyelid margin (Figure 1). Once an opening is identified, a drop of topical anesthetic is instilled into the eye through the opening. If a gap is present, all attempts to visually inspect the eye through the fissure are made. The blunt end of a Jameson muscle hook is then inserted through the identified opening, and the hook is rotated so that the distal element of the hook is normal to the surface of the eye (Figure 2). Next, the hook is pulled through the site of the eyelid adhesion by pulling the hook simultaneous parallel to the lid margins and slightly upward and away from the surface of the eye so that it minimizes any contact between the bulb of the hook and the eye. Counter pressure in the opposite direction of the muscle hook can be applied with the fellow hand. When all the sites of adhesion have been released and the eye is fully opened, residual glue from the eyelashes or around the eyelid can be carefully trimmed with blunt-tip scissors. The remaining glue will slough off over the course of the next several days (7). DISCUSSION Cyanoacrylate glue is a widely available adhesive commonly found in households; it is a monomer of cyanoacetate and formaldehyde, which polymerizes within seconds on dry surfaces, such as eyelid margins. Ophthalmic exposure can result in conjunctival abrasion, chemical conjunctivitis, corneal abrasion, keratitis, or eyelid adhesions (5). When exposure to the ocular surfaces occurs, the immediate response tends to be forceful
Figure 1. Illustration demonstrating technique to relieve eyelid adhesions. (A) Carefully examine the eyelids and manually apply opposite vector forces along the eyelid
margin to identify any opening in the lid fissure. (B) Instill a drop of topical anesthetic through the opening in the lid fissure. (C) Insert the blunt end of a Jameson muscle hook through the identified opening and rotate the hook so that the distal element of the hook is normal to the surface of the eye. (D) Pull the hook parallel to the lid margins and through the site of the eyelid adhesion. Counter pressure in the opposite direction of the muscle hook can be applied with the fellow hand. (E) Re-examine the eyelids to ensure all adhesion sites are cleaved and the eye is fully opened. Residual glue from the eyelashes or around the eyelid can be carefully trimmed with blunt-tip scissors.
Opening Superglued Lids
3
patients, for whom cooperation with lash trimming can be difficult, and for whom observation alone is frequently unwanted by families, uncomfortable for patients, and unacceptable to physicians desiring to evaluate the ocular surface for further injury. This technique may have several advantages over others described, including ease and simplicity, avoidance of caustic agents (i.e., acetone) adjacent to the ocular surface, and the absence of a requirement for general anesthesia. This technique has been used in our resident ophthalmology clinic, Children’s of Alabama, and at the Callahan Eye Hospital for >10 years without complication and has been successful in releasing all cases of chemical adhesion-induced tarsorrhaphy. CONCLUSIONS
Figure 2. (A) Child with adhesion of right upper and lower eyelids secondary to accidental cyanoacrylate application. (B) Placement of Jameson muscle hook being pulled parallel to lid margin to relieve adhesion. (C) Child with relief of eyelid adhesion after executing the technique described.
The technique described in this article is a simple, effective, and safe treatment option for both pediatric and adult patients with cyanoacrylate-induced adhesion of eyelids, who often first present to their local emergency department for treatment. This method, which does not involve placing any sharp instruments near the eye, has been used successfully by physicians at the University of Alabama at Birmingham Hospital and affiliated locations without complication.
REFERENCES closing of the eyelids due to a sensation of burning that effectively results in a chemical tarsorrhaphy. The incidence of ocular injury due to cyanoacrylate adhesive is not known and varies widely from 53 cases (25% of which were children) reported in the literature in the preceding 30 years up to the time of publication of Reddy, 2012 as compared with a reported 105 cases in just a 3-month time period at Farabi Eye Hospital (5,6). Management strategies in the literature vary from observation, to attempted manual forceful opening, to chemical dissolution (e.g., with acetone), to administration of general anesthesia followed by lash trimming in the operating room. This latter option has been the procedure of choice for especially young
1. Margo CE, Trobe JD. Tarsorrhaphy from accidental instillation of cyanoacrylate adhesive in the eye. JAMA 1982;247:660–1. 2. Yusuf IH, Patel CK. A sticky sight: cyanoacrylate ‘‘superglue’’ injuries of the eye. BMJ Case Rep 2010;2010. 3. McLean CJ. Ocular superglue injury. J Accid Emerg Med 1997;14: 40–1. 4. Good AM, McCabe SE. Superglue accidents and the eye—causes and prevention. Br J Ophthalmol 1994;78:802. 5. Reddy SC. Superglue injuries of the eye. Int J Ophthalmol 2012;5: 634–7. 6. Tabatabaei SA, Modanloo S, Ghiyasvand AM, et al. Epidemiological aspects of ocular superglue injuries. Int J Ophthalmol 2016;9: 278–81. 7. Yee J, Austin T. Getting out of a sticky situation. Review of Ophthalmology. Available at: http://www.reviewofophthalmology.com/ content/d/features/i/1326/c/25457/. Published October 28, 2004. Accessed June 25, 2016.