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Emergency Medicine Australasia (2014) 26, 200–207
CASE LETTERS
Cyanoacrylate glue on skin lacerations near the eyes Dear Editor, We report a case of accidental iatrogenic eyelid gluing with cyanoacrylate topical skin adhesive (TSA) following closure of a forehead laceration in a child. In EDs, TSAs are the preferred method of treating short, facial lacerations, especially in children.1 Special precautions are necessary to avoid inadvertent involvement of nearby vital structures, particularly the eyes. A 4-year-old girl attended a local rural ED, having sustained a 1.25 cm, linear laceration, located above the left eyebrow. The wound was appropriately irrigated and prepared. A towel was placed over the eye on the affected side, before application of the cyanoacrylate TSA (SurgiSeal®, Adhezion Biomedical, LLC, Wyomissing, PA, USA). During application, the adhesive inadvertently seeped down beneath the towel to the left eye, gluing together both upper and lower eyelashes. Attempts to manually separate the eyelids were unsuccessful. Referral to the Royal Victorian Eye and Ear Hospital was made. With the aid of a slitlamp, the adhering eyelashes were cut, allowing separation of the eyelids and examination of the eye. Ocular examination revealed no corneal glue deposition or epithelial defects. On follow up 3 days later, the patient had no visual complaints and no restriction in eye movement or eyelid opening. The trimmed eyelashes remained caked with glue, but no inward pointing eyelashes were noted (Fig. 1). Referral to a local optometrist for ongoing review was made. This case emphasises the need for standardised precautions when applying TSAs on wounds in proximity to the eye. Previous reports have described inadvertent eyelid gluing
secondary to TSA application for facial lacerations, causing prolonged eyelid closure for up to 6 days, distressing visual loss, corneal abrasions and possible medicolegal implications. 2,3 Placing an eye pad or moist gauze over the eye has been suggested, but as illustrated in this case, this precaution alone is insufficient. We recommend closing the eyelids and covering the eyelashes with a small piece of a hypoallergenic paper tape. This will preclude rapid polymerisation of excess adhesive on contact with the moist edge of the tarsal conjunctiva. Placing the patient in the Trendelenburg position for supraorbital wounds and reverse Trendelenberg for infraorbital
wounds will direct run-off away from the eye.4 Cautious and economical application of a high-viscosity TSA will also aid to minimise run-off. In the event of iatrogenic eyelid gluing, same-day ophthalmology referral is recommended. Younger children are at risk of occlusive amblyopia if the eye is left closed for an extended period of time. Careful cutting of the eyelashes by an ophthalmologist might be required to provide relief of the eyelid closure and patient distress. Follow up is needed to ensure proper healing and that complications do not occur. The alternative of using petroleum jelly-soaked cotton buds, to pry open eyelashes from
Figure 1. Three days after accidental iatrogenic eyelid gluing. Trimmed eyelashes remained caked with glue. No inward pointing eyelashes or corneal epithelial defects are noted.
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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201
CASE LETTERS
underneath, has been described.3 This is not always feasible if the entire eyelash border is adherent. Care is required when manipulating the cotton bud without visualisation underneath. Other substances such as chlorhexidine gluconate, soap and acetone, which are toxic to the eye, must be avoided. Special care is necessary in all cases of facial lacerations treated with cyanoacrylate TSA. Standardised precautions before application, including tape over the eyelids, positioning of the patient appropriately and the use of high-viscosity TSAs, will minimise cases of iatrogenic eyelid gluing.
Competing interests None declared.
References 1. Singer AJ, Kinariwala M, Lirov R, Thode HC Jr. Patterns of use of topical skin adhesives in the emergency department. Acad. Emerg. Med. 2010; 17: 670–2. 2. Coutts SJ, Sandhu R, Geh VSY. Tissue glue and iatrogenic eyelid gluing in children. Pediatr. Emerg. Care 2012; 28: 810–1. 3. Rouvelas H, Saffra N, Rosen M. Inadvertent tarsorrhaphy secondary to
Dermabond. Pediatr. Emerg. Care 2000; 16: 346. 4. Singer AJ, Quinn JV, Hollander JE. The cyanoacrylate topical skin adhesives. Am. J. Emerg. Med. 2008; 26: 490–6.
Thomas J GIN,1 Jonathan K KAM2 and Carmel CROCK2 1 The Royal Melbourne Hospital, Melbourne, Victoria, Australia, and 2 Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia doi: 10.1111/1742-6723.12169
Delayed presentation and diagnosis of Boerhaave’s syndrome Dear Editor, Boerhaave’s syndrome is a spontaneous rupture of the oesophagus, secondary to a sudden increase in intraoesophageal pressure, which is usually associated with straining or vomiting. A 37-year-old man from eastern Nepal was initially admitted to a peripheral hospital for 4 days with the following history: 3 days of acute epigastric pain, radiating to the back, with no alleviating or aggravating factors. His pain began after several episodes of non-projectile vomiting. The patient also stated that he had consumed several units of alcohol just a few hours before the onset of symptoms. He was diagnosed with acute severe pancreatitis, despite normal serum amylase and lipase levels. His initial CXR was normal. Six days after symptom onset, he developed left-sided chest pain, neck swelling and shortness of breath. He was referred to the ED at Tribhuvan University Teaching Hospital in Kathmandu. There was no history of trauma, fever, cough or similar episodes in the past. There was no history
of pulmonary tuberculosis or abdominal surgery. His vital signs were as follows: BP 120/90 mmHg, PR 116/ min, RR 24/min, SpO2 84% on room air, and he was afebrile. There was subcutaneous emphysema over the upper anterior chest wall and the neck. The patient also had decreased air entry bilaterally with coarse crepitations on the left side. CXR showed bilateral pleural effusions, pneumo-mediastinum and subcutaneous emphysema (Fig. 1). There was a 12 h delay in correct diagnosis following the CXR because of junior medical staff misinterpreting the film and the clinical scenario. CT chest confirmed the (CXR) findings, and also showed an air leak from the oesophagus into the left hemithorax, confirming an oesophageal rupture. The patient underwent an oesophageal resection-oesophagostomy by a cervical approach with feeding jejunostomy. Six weeks later he underwent gastric pull-up with gastrooesophageal anastomosis, with an intial smooth postoperative course. Five months after first admission, he returned with complaints of vague
chest discomfort and left hypochondrial pain. He was diagnosed with an oesphagocele following endoscopy and CT abdomen. Boerhaave’s syndrome is a rare condition with various clinical presentations. It is more common in men, with a mean age between 40 and 60 years. The typical presentation is of Mackler’s triad of vomiting, chest pain and surgical emphysema.1 Atypical presentations, where the diagnosis was not suspected initially, have been described in Nepal. 2 Symptoms can be confused with dyspepsia, myocardial infarction, pancreatitis, dissecting aneurysm, pneumonia or spontaneous pneumothorax. For early diagnosis, the keys are a careful history, high clinical suspicion and the presence of mediastinal and cervical air on CXR. The surgical intervention recommended, irrespective of the duration of the oesophageal rupture, is prompt primary suture closure with reinforcement of the suture line with a well-vascularised pedicled tissue flap.3 Oesophageal resection and diversion is the last resort in patients with sepsis
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Emergency Medicine Australasia (2014) 26, 200–207
CASE LETTERS
Cyanoacrylate glue on skin lacerations near the eyes Dear Editor, We report a case of accidental iatrogenic eyelid gluing with cyanoacrylate topical skin adhesive (TSA) following closure of a forehead laceration in a child. In EDs, TSAs are the preferred method of treating short, facial lacerations, especially in children.1 Special precautions are necessary to avoid inadvertent involvement of nearby vital structures, particularly the eyes. A 4-year-old girl attended a local rural ED, having sustained a 1.25 cm, linear laceration, located above the left eyebrow. The wound was appropriately irrigated and prepared. A towel was placed over the eye on the affected side, before application of the cyanoacrylate TSA (SurgiSeal®, Adhezion Biomedical, LLC, Wyomissing, PA, USA). During application, the adhesive inadvertently seeped down beneath the towel to the left eye, gluing together both upper and lower eyelashes. Attempts to manually separate the eyelids were unsuccessful. Referral to the Royal Victorian Eye and Ear Hospital was made. With the aid of a slitlamp, the adhering eyelashes were cut, allowing separation of the eyelids and examination of the eye. Ocular examination revealed no corneal glue deposition or epithelial defects. On follow up 3 days later, the patient had no visual complaints and no restriction in eye movement or eyelid opening. The trimmed eyelashes remained caked with glue, but no inward pointing eyelashes were noted (Fig. 1). Referral to a local optometrist for ongoing review was made. This case emphasises the need for standardised precautions when applying TSAs on wounds in proximity to the eye. Previous reports have described inadvertent eyelid gluing
secondary to TSA application for facial lacerations, causing prolonged eyelid closure for up to 6 days, distressing visual loss, corneal abrasions and possible medicolegal implications. 2,3 Placing an eye pad or moist gauze over the eye has been suggested, but as illustrated in this case, this precaution alone is insufficient. We recommend closing the eyelids and covering the eyelashes with a small piece of a hypoallergenic paper tape. This will preclude rapid polymerisation of excess adhesive on contact with the moist edge of the tarsal conjunctiva. Placing the patient in the Trendelenburg position for supraorbital wounds and reverse Trendelenberg for infraorbital
wounds will direct run-off away from the eye.4 Cautious and economical application of a high-viscosity TSA will also aid to minimise run-off. In the event of iatrogenic eyelid gluing, same-day ophthalmology referral is recommended. Younger children are at risk of occlusive amblyopia if the eye is left closed for an extended period of time. Careful cutting of the eyelashes by an ophthalmologist might be required to provide relief of the eyelid closure and patient distress. Follow up is needed to ensure proper healing and that complications do not occur. The alternative of using petroleum jelly-soaked cotton buds, to pry open eyelashes from
Figure 1. Three days after accidental iatrogenic eyelid gluing. Trimmed eyelashes remained caked with glue. No inward pointing eyelashes or corneal epithelial defects are noted.
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
bs_bs_banner
201
CASE LETTERS
underneath, has been described.3 This is not always feasible if the entire eyelash border is adherent. Care is required when manipulating the cotton bud without visualisation underneath. Other substances such as chlorhexidine gluconate, soap and acetone, which are toxic to the eye, must be avoided. Special care is necessary in all cases of facial lacerations treated with cyanoacrylate TSA. Standardised precautions before application, including tape over the eyelids, positioning of the patient appropriately and the use of high-viscosity TSAs, will minimise cases of iatrogenic eyelid gluing.
Competing interests None declared.
References 1. Singer AJ, Kinariwala M, Lirov R, Thode HC Jr. Patterns of use of topical skin adhesives in the emergency department. Acad. Emerg. Med. 2010; 17: 670–2. 2. Coutts SJ, Sandhu R, Geh VSY. Tissue glue and iatrogenic eyelid gluing in children. Pediatr. Emerg. Care 2012; 28: 810–1. 3. Rouvelas H, Saffra N, Rosen M. Inadvertent tarsorrhaphy secondary to
Dermabond. Pediatr. Emerg. Care 2000; 16: 346. 4. Singer AJ, Quinn JV, Hollander JE. The cyanoacrylate topical skin adhesives. Am. J. Emerg. Med. 2008; 26: 490–6.
Thomas J GIN,1 Jonathan K KAM2 and Carmel CROCK2 1 The Royal Melbourne Hospital, Melbourne, Victoria, Australia, and 2 Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia doi: 10.1111/1742-6723.12169
Delayed presentation and diagnosis of Boerhaave’s syndrome Dear Editor, Boerhaave’s syndrome is a spontaneous rupture of the oesophagus, secondary to a sudden increase in intraoesophageal pressure, which is usually associated with straining or vomiting. A 37-year-old man from eastern Nepal was initially admitted to a peripheral hospital for 4 days with the following history: 3 days of acute epigastric pain, radiating to the back, with no alleviating or aggravating factors. His pain began after several episodes of non-projectile vomiting. The patient also stated that he had consumed several units of alcohol just a few hours before the onset of symptoms. He was diagnosed with acute severe pancreatitis, despite normal serum amylase and lipase levels. His initial CXR was normal. Six days after symptom onset, he developed left-sided chest pain, neck swelling and shortness of breath. He was referred to the ED at Tribhuvan University Teaching Hospital in Kathmandu. There was no history of trauma, fever, cough or similar episodes in the past. There was no history
of pulmonary tuberculosis or abdominal surgery. His vital signs were as follows: BP 120/90 mmHg, PR 116/ min, RR 24/min, SpO2 84% on room air, and he was afebrile. There was subcutaneous emphysema over the upper anterior chest wall and the neck. The patient also had decreased air entry bilaterally with coarse crepitations on the left side. CXR showed bilateral pleural effusions, pneumo-mediastinum and subcutaneous emphysema (Fig. 1). There was a 12 h delay in correct diagnosis following the CXR because of junior medical staff misinterpreting the film and the clinical scenario. CT chest confirmed the (CXR) findings, and also showed an air leak from the oesophagus into the left hemithorax, confirming an oesophageal rupture. The patient underwent an oesophageal resection-oesophagostomy by a cervical approach with feeding jejunostomy. Six weeks later he underwent gastric pull-up with gastrooesophageal anastomosis, with an intial smooth postoperative course. Five months after first admission, he returned with complaints of vague
chest discomfort and left hypochondrial pain. He was diagnosed with an oesphagocele following endoscopy and CT abdomen. Boerhaave’s syndrome is a rare condition with various clinical presentations. It is more common in men, with a mean age between 40 and 60 years. The typical presentation is of Mackler’s triad of vomiting, chest pain and surgical emphysema.1 Atypical presentations, where the diagnosis was not suspected initially, have been described in Nepal. 2 Symptoms can be confused with dyspepsia, myocardial infarction, pancreatitis, dissecting aneurysm, pneumonia or spontaneous pneumothorax. For early diagnosis, the keys are a careful history, high clinical suspicion and the presence of mediastinal and cervical air on CXR. The surgical intervention recommended, irrespective of the duration of the oesophageal rupture, is prompt primary suture closure with reinforcement of the suture line with a well-vascularised pedicled tissue flap.3 Oesophageal resection and diversion is the last resort in patients with sepsis
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
