contact lens case reports
Fixing the Leaky Cornea
BY PATRICK J. CAROLINE, FAAO, & MARK P. ANDRÉ, FAAO

Corneal perforations result from a wide range of ocular conditions. The immediate treatment goal is to seal the leak to prevent further loss of aqueous to avoid iris prolapse and a flat anterior chamber. Therapeutic soft contact lenses seal defects and aid in healing small wounds.

Figure 1. Isobutyl 2-cyanolacrylate (Histoacryl) tissue adhesive.

However, if the wound is large or of a shape in which case suturing won't achieve a water-tight closure, then you can seal defects with a tissue adhesive, cyanoacrylate glue (Figure 1).

The glue creates a water-tight seal that allows for rapid anterior chamber reformation. The glue also inhibits infiltration of tear and stromal polymorphonuclear leukocytes and has some antibacterial activity (factors that help prevent stromal melting).

	Figure 2. Post corneal ulcer perforation sealed with a stromal patch.

We generally use tissue adhesives for perforations of 1mm or smaller. Consider sealing larger perforations with a small stromal patch graft. The patch plugs the perforation and keeps the glue out of the anterior chamber (Figure 2).

Case Presentation

Patient DW, a 52-year-old electrician, presented with a .05mm traumatic corneal perforation to his left eye secondary to an airborne iron wire. The perforation was too large for a therapeutic soft contact lens seal, therefore, we prepped the patient for the application of Histoacryl glue.

We began by first debriding necrotic epithelium from the defect's edge, leaving a 1 mm zone of healthy Bowman's. We injected sodium hyaluronate into the anterior chamber to prevent iris incarceration into the wound and to keep the glue from touching the crystalline lens. We put a small amount of glue onto the defect and allowed it to set for between one and two minutes (Figure 3). We checked for leakage with fluorescein and placed a silicone hydrogel soft contact lens on the eye to protect the lid from irritation from the glue's rough surface and also to prevent glue dislocation by the upper lid. We left the glue in place until it spontaneously sloughed off (secondary to wound healing), which took about six weeks.

Figure 3. Patient DW following application of the tissue adhesive.

Discussion

Tissue adhesives play an important role in treating certain traumatic or ulcerative disorders in which progressive corneal thinning or perforations occur. It's important to remember that the primary goal in treating corneal perforations is to restore the anterior chamber as quickly and as atraumatically as possible. And, to that end, therapeutic soft contact lenses may serve a primary role in sealing small defects or a secondary role following the application of tissue adhesive.

Patrick Caroline is an associate professor of optometry at Pacific University and is an assistant professor of ophthalmology at the Oregon Health Sciences University. Mark André is director of contact lens services at the Oregon Health Sciences University and serves as an assistant professor of optometry at Pacific University.