Corneal Glue Indications in Keratitis
Cyanoacrylate tissue adhesive is indicated in keratitis for small corneal perforations ≤3 mm, impending perforations with marked thinning, and early descemetoceles—but only when the infection is resolving under antimicrobial control, the defect sits at the bottom of a crater (not a ballooning descemetocele), and the base is clean, compact, and completely dry. 1, 2
Primary Indications for Tissue Adhesive
Small perforations and impending perforations:
- Perforations ≤3 mm in diameter are ideal candidates for cyanoacrylate glue alone 1, 2
- Extremely thin cornea with impending perforation complicating bacterial keratitis 2
- Early descemetoceles with marked thinning 2
Critical anatomic requirements:
- The defect must be located at the bottom of a crater, not on a ballooning descemetocele (glue fails on convex surfaces) 1, 2
- The base must be clean, compact, and completely dry—moisture prevents proper adhesion 1, 2
- Peripheral locations may allow definitive treatment, while central/paracentral locations typically serve as temporizing measures before elective repair 2
When Tissue Adhesive Fails: Use Alternative Approaches
For perforations >3 mm:
- Tenon's patch graft with cyanoacrylate glue is the preferred approach, achieving 93% successful tectonic restoration 3, 1
- This technique is specifically recommended by the American Academy of Ophthalmology for larger perforations 3
When amniotic membrane transplantation (AMT) should be prioritized over glue alone:
- Perforation size exceeds 3 mm 1
- Ballooning descemetocele present rather than crater base 1
- Wound cannot be adequately dried 1
- Progressive corneal melting with active infection requiring continued aggressive antimicrobial therapy 1
- Cases refractory to medical treatment where you need to stabilize the ocular surface and avoid urgent keratoplasty 1
Application Technique and Management
Pre-application requirements:
- Ensure the underlying infection is resolving and under control with appropriate antimicrobial therapy 2
- For leaking descemetoceles, inject an air bubble into the anterior chamber to temporarily halt leakage during glue application 2
- Completely dry the wound base before application 1, 2
Application method:
- Apply using a 30-gauge needle, wooden end of cotton applicator, or micropipette 2
- Use the minimum quantity necessary to seal or support the defect 2
- A thin layer can remain in place for 6 weeks or longer if applied to a clean and compact base 2
Post-application care:
- Apply a bandage contact lens immediately after glue application to prevent dislocation and provide comfort 2, 4
- Continue appropriate antimicrobial therapy for the underlying keratitis 2
- Switch topical antibiotics every 15 days until glue removal to minimize infection risk 4
Critical Pitfalls and Complications
Infection risk with glue:
- Infectious keratitis can develop after cyanoacrylate gluing despite prophylactic antibiotics, including methicillin-resistant organisms and fungal infections 5
- The opaqueness of glue can conceal underlying infection and perforation progression 5
- Pain from infectious ulcers may be obscured by ocular surface irritation from the glue 5
- Vigilance in monitoring for infection is necessary, especially when glue has been present for >6 weeks 6
Never use fibrin glue:
- Fibrin glue biodegrades too rapidly before corneal healing occurs and is contraindicated for corneal perforations or descemetoceles 1, 2
- Only cyanoacrylate tissue adhesive provides adequate duration (6+ weeks) for corneal healing 1
Timing Considerations
When infection is present:
- Apply glue only after addressing the underlying infection with antimicrobial therapy 2
- The infection must be resolving and under control before glue application 1
- For cases with progressive melting despite antimicrobials, prioritize AMT over glue alone 1
Role as temporizing measure: