Nail glue injuries to the eye: assessment of two cases

We herein report 2 cases of ocular injuries in adults caused by accidental instillation of nail glue to the eye seen within 1 week. On October 24, 2020, a 50-year-old woman presented to the emergency room of the Montreal General Hospital 1 day after inadvertently instilling a drop of nail glue into her right eye. The nail glue was stored in a bottle roughly the same size and shape as her regular artificial tear drops (Fig. 1). The eyelids were instantly stuck together and the patient experienced severe discomfort and burning sensation in her eye. Saline irrigation, warm compress, and gentle pulling of the eyelids were attempted by the emergency physician, which opened up the medial third of the eyelids. Upon examination in the emergency eye clinic, the lateral two-thirds of her right eyelids remained stuck shut, with dried glue visible externally. She had significant eyelid inflammation, conjunctival injection, and an epithelial erosion measuring 4 mm in diameter covering the inferolateral right cornea (Fig. 2A). The eyelashes were cut using Westcott scissors, but the eyelids margin adhesion remained. Erythromycin ointment was prescribed. The patient was instructed to apply a warm compress and scrub the lid with baby shampoo at home. At the 48-hour follow-up, the patient remained in pain, the lateral two-third of the eyelids’ margins remained unchanged, and the corneal abrasion did not decrease in size. The decision was made to consult our ophthalmic plastic service in order to surgically separate the eyelids. After topical ocular and local eyelid anesthesia, a Jameson muscle hook was inserted through the medial opening to distract the glued eyelids’ margin from the bulbar surface, then the eyelids margins were bluntly separated using Stevens scissors using a spreading motion without damaging the eyelid margins. Several pieces of dried glue were removed from the eyelids before they were successfully separated (Fig. 2B). Erythromycin ointment was given, and the eye was patched. At the next 48-hour follow-up, the corneal abrasion had healed.

On November 1, 2020, a 19-year-old woman presented to the emergency department at the Royal Victoria Hospital right after attempting to use nail glue to glue her fake eyelashes onto her left eye. This inadvertently caused the lateral third aspect of the eyelids to be glued shut. She was complaining of severe eye pain in addition to foreign body sensation. The emergency physician successfully opened the eyelid using gentle pulling of the eyelids. She was seen by the ophthalmologist the subsequent day and was already feeling better, but she still complained of some left eye pain. She suffered from a superotemporal epithelial defect measuring 1 × 2 mm. The residual glue on the eyelashes was cut using Westcott scissors.

This is not the first report on ocular injury caused by nail glue, but little to nothing has been done to prevent these injuries from recurring. Although limited, the exposure to nail glue can be harmful and presents with varying degrees of severity. Uncontrolled instillation of glue in the eye invariably causes acute severe pain and psychological distress. In addition, the sequelae vary from a mild chemical keratoconjunctivitis to a complete symblepharon-like situation requiring immediate advanced medical attention.

Cyanoacrylates are the most dangerous nail glue components. In contact with water, cyanoacrylates polymerize in an exothermic reaction.^,  This allowed for their medical implementations in skin closure and endovascular embolization. However, industrial cyanoacrylate, which shares the same characteristics of medical-grade cyanoacrylate, tends to be more caustic to mucosal tissue and can cause irreversible injuries when applied in a noncontrolled fashion.^, 

Poison control centers suggest treating the insults based on the presenting symptoms. Glue should be removed gently, and the affected area must be well irrigated with saline. In the advent of lid closure, no attempt at separating them should be performed given the risk of further damaging the surrounding tissues.

Cyanoacrylate-based nail glue manufacturers elected to commercialize their product in small and practical containers. However, the containers are identical to ophthalmic drops bottles. As a result, children, individuals using artificial tears, and patients who are visually impaired fail at discriminating between the ophthalmic drops and the glue dispenser.^,  In a series of 42 patients, from 2007 to 2020, Brambilla et al. (2020) reported 32 (76%) cases of varying degrees of dermal and ocular pathologies associated with nail glue/false eyelash glue, with an age range of 1–42.

To date, only measures based on child-resistant packaging are in place but none with regards to the designs sharing similarities to that of eye drop containers. A suggested course of action in initiating policy change would entail an update to the “Consumer Chemicals and Containers Regulations, 2001” of Canada that specifies the packaging design of commercially available cyanoacrylates must drastically differ from that of eye drop containers.

The adverse events reporting process to Health Canada should remain case-based, in which a centralized database is kept to audit the safety of the regulations in place. Standardized regulations to readily distinguish the industrial design of medical products from nonmedical chemical containers should be established for all products sold on Canadian territory regardless of their origin. This includes optimized child-resistant caps and a distinct tactile design that is visually different from that of regular eyedrop containers. Compliance failure should ban the product and lead to the immediate recall of the sold items. We herein highlight and reiterate the importance of distinguishing the industrial design of such containers and encourage fellow ophthalmologists to further report these relatively common injuries using the reporting mechanisms in place by Health Canada.

Inadvertent ocular installation of fast-acting adhesives has been reported since the early 1980s. Despite being an old topic, the public health concern surrounding nail glue injuries must be reiterated. Until tangible changes are made in the industrial design of nail glue dispensers, preventable ocular injuries will keep recurring. Containers should be easily identifiable and distinct from ophthalmic drop containers. It is the responsibility of every ophthalmologist to be aware of these types of injuries, understand the seriousness of their repercussions, educate the public, and report them to Health Canada (www.hc-sc.gc.ca/cps-spc/advisories-avis/incident/index-eng.php).