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Corneal PerforationEdit

Corneal perforation is a full-thickness defect in the cornea that creates a conduit between the exterior environment and the anterior chamber of the eye. The cornea, the transparent front window of the eye, serves critical roles in clarity of vision and protection against infection. When perforation occurs, the eye is at imminent risk of infection, structural collapse of the globe, and rapid loss of vision if not managed promptly. Corneal perforation is considered an ophthalmic emergency requiring urgent evaluation and intervention by specialists in ophthalmology and related fields. The condition can range from tiny microperforations to large, full-thickness wounds and may vary in location from peripheral to central, which has important implications for prognosis and treatment.

Corneal perforation most commonly arises from a combination of tissue loss and mechanical disruption, but a wide range of etiologies can contribute. Prompt recognition and management depend on understanding these causes, the clinical presentation, and the available therapeutic options. While some perforations respond to rapid medical stabilization and temporary tectonic measures, others require complex surgical repair to restore globe integrity and vision. The goal in all cases is to seal the defect, prevent infection, maintain a stable anterior chamber, and preserve visual potential.

Causes

  • Trauma and surgical complications: Penetrating injuries from sharp objects or projectiles, as well as iatrogenic injuries during ocular procedures, can produce direct corneal perforation. Iatrogenic perforations may occur during cataract surgery, keratoplasty, or other anterior segment procedures. See also trauma and surgical complications.

  • Infectious keratitis: Severe corneal infection from bacteria, fungi, or parasites can lead to progressive thinning and rupture of the cornea. Common infectious etiologies include bacterial keratitis and fungal keratitis, with virulent organisms capable of rapidly eroding corneal tissue. See bacterial keratitis and fungal keratitis for related material.

  • Chemical injuries: Chemical burns, especially alkaline injuries, disrupt corneal tissue and can precipitate rapid tissue necrosis and perforation. The damage pattern and the quality of wound healing influence the likelihood of perforation. See chemical burn for broader context.

  • Immune-mediated and inflammatory processes: Severe peripheral ulcerative conditions such as Mooren’s ulcer or other autoimmune inflammatory processes can progressively destroy corneal tissue, increasing the risk of perforation. See Mooren's ulcer for a detailed discussion of this specific entity.

  • Other ocular surface disease and conditions: Descemetoceles (bulging of Descemet’s membrane) or severe thinning from ocular surface disease can progress to perforation if not contained. Postoperative healing failures or complications from contact lens wear in certain settings can also contribute.

Presentation and diagnosis

  • Symptoms: Sudden eye pain, tearing, redness, photophobia, and a potential rapid decline in vision are typical when perforation occurs. In some cases, patients may have a history of ocular trauma or severe keratitis preceding the event.

  • Signs and testing: A visible corneal defect or iris protrusion into the wound can be observed on slit-lamp examination. A Seidel test using fluorescein dye is commonly employed to detect aqueous leakage from the anterior chamber, signaling perforation. An anterior chamber may be shallow or flatten, and there may be iris defects or prolapse. Imaging such as anterior segment optical coherence tomography (AS-OCT) or ultrasound B-scan may aid assessment when view is limited.

  • Differential diagnosis: Other causes of acute corneal thinning or wound leakage should be considered, including infectious keratitis with necrotic tissue, post-surgical complications, and significant chemical injury without frank perforation.

Management

  • Immediate stabilization: Corneal perforation is an emergency. Initial management focuses on preserving globe integrity, reducing pain, and preventing infection. This typically includes protective shielding, topical broad-spectrum antibiotics, cycloplegics for pain control, and consideration of systemic analgesia. Tetanus prophylaxis may be indicated as part of standard wound care.

  • Temporary measures to seal small perforations: For small, peripheral perforations, adhesive methods such as cyanoacrylate tissue glue combined with a bandage contact lens can provide rapid tectonic support and allow time for healing. Temporary amniotic membrane grafts may support healing and reduce inflammation in certain cases.

  • Surgical repair for larger or central perforations: Larger defects or central perforations often require surgical repair to restore ocular integrity and maintain vision. Options include tectonic keratoplasty (lamellar or penetrating grafts), suture repair of corneal lacerations, and, in severe or recurrent cases, keratoprosthesis. The choice depends on perforation size, location, tissue availability, and the status of the corneal and posterior segment.

  • Adjunctive therapies: Broad-spectrum antibacterial coverage remains critical to prevent endophthalmitis, especially if perforation is suspected to be contaminated. In cases of fungal keratitis, targeted antifungal therapy is essential. Where inflammation is prominent, careful use and timing of anti-inflammatory medications must balance healing with infection risk. In some instances, amniotic membrane transplantation amniotic membrane transplantation can aid epithelial healing and reduce scarring.

  • Long-term care and follow-up: After initial stabilization, ongoing management focuses on preventing reinfection, promoting epithelial healing, and planning for definitive tectonic or optical rehabilitation as indicated. This may involve collaboration with corneal specialists and rehabilitation services.

Prognosis

  • Outcomes vary widely with perforation size, location, and the underlying cause. Peripheral or small perforations with prompt sealing have a better chance of healing and preserving vision, whereas central, large, or delayed cases carry higher risks of persistent scarring, irregular astigmatism, glaucoma from angle involvement, or other complications. The prognosis is also influenced by the presence of concomitant infections or inflammatory disease and by access to timely surgical expertise when needed.

Prevention

  • Protective measures: Eye protection in environments with potential for trauma, and safe handling of sharp objects, can prevent many trauma-related perforations.

  • Infections and inflammation: Early treatment of severe keratitis and aggressive management of ocular surface disease reduce the risk of progression to perforation. Prompt care for chemical injuries and strict adherence to antimicrobial regimens are important.

  • Postoperative care: Adherence to postoperative instructions after anterior segment surgery minimizes the risk of wound complications and perforation.

See also