Elsevier

Survey of Ophthalmology

Volume 56, Issue 6, November–December 2011, Pages 522-538
Survey of Ophthalmology

Major Review
Management of Corneal Perforation

https://doi.org/10.1016/j.survophthal.2011.06.003Get rights and content

Abstract

Corneal perforation may be associated with prolapse of ocular tissue and requires prompt diagnosis and treatment. Although infectious keratitis is an important cause, corneal xerosis and collagen vascular diseases should be considered in the differential diagnosis, especially in cases that do not respond to conventional medical therapy. Although medical therapy is a useful adjunct, a surgical approach is required for most corneal perforations. Depending on the size and location of the corneal perforation, treatment options include gluing, amniotic membrane transplantation, and corneal transplantation.

Introduction

Corneal perforation is a cause of ocular morbidity and profound visual loss.13, 119 It is the end result of various infectious and noninfectious disorders that include microbial keratitis, trauma, and immune disorders. Although of low prevalence in the developed world, it accounts for a large number of cases requiring an urgent surgical intervention in developing countries.111, 131 Eyes with corneal perforation need immediate treatment in order to preserve the anatomic integrity of the cornea and to prevent complications such as secondary glaucoma or endophthalmitis. Management of corneal perforation may range from temporary measures, such as application of bandage contact lens and gluing, to definitive treatment such as corneal transplantation. The selection of an appropriate treatment option is mostly guided by size and location of the perforation and the status of the underlying disease.

Section snippets

Disorders Leading to Corneal Perforation

Corneal melting and subsequent perforation is a classic feature of corneal ulcers that do not respond to medical therapy. One of the most important events leading to corneal thinning and perforation is a breach in the corneal epithelium; however, a few organisms such as Corynebacterium diphtheriae, Haemophilus aegyptius, Neisseria gonorrhoeae, and N. meningitidis, and Shigella and Listeria species can penetrate an intact epithelium.95 Occasionally, keratitis can be established via the

History and Corneal Work-up

Corneal perforation requires prompt management. Most patients with corneal perforation experience a sudden drop in visual acuity with associated ocular pain. Relevant ophthalmic history includes ocular trauma, ocular surgery, contact lens use, herpetic eye disease, dry eyes, or use of topical corticosteroids. All patients should be asked about rheumatoid arthritis, lupus, and immunosuppression as it is imperative that systemic medications be administered in the setting of systemic autoimmune

Treating the Infectious Cause

When microbial infection is suspected as a cause of corneal perforations, rapid diagnosis and treatment are essential to increase the success of surgery. Monotherapy with fluoroquinolones has been shown to result in shorter duration of intensive therapy and shorter hospital stay when compared with traditional combined fortified therapy.64, 105, 109, 155 The newer generation fluoroquinolones offer enhanced transcorneal penetration without any apparent disadvantages.30, 55, 79, 134 The

Conclusion

Corneal perforation results from a variety of infectious and noninfectious disorders and requires prompt management. Successful medical and surgical treatment also rely upon control of ocular surface disease, neurotrophic factors, and systemic autoimmune conditions when present. Although small perforations respond reasonably well to corneal gluing techniques, peripheral perforations can be best managed with a partial conjunctival flap or tectonic keratoplasty. Large perforations and those

Method of Literature Search

PubMed was queried with combinations not limited to the following search terms: corneal perforation, corneal gluing, corneal transplantation, management, keratoplasty, therapeutic keratoplasty, and epidemiology. A review of the search results was performed and relevant articles to the topics of clinical manifestations and treatment were included. Relevant articles to the management of corneal perforations in various conditions were also included. Case reports without additional value over

Disclosure

The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.

References (177)

  • C.S. De Paiva et al.

    Corticosteroid and doxycycline suppress MMP-9 and inflammatory cytokine expression, MAPK activation in the corneal epithelium in experimental dry eye

    Exp Eye Res

    (2006)
  • D. Dursun et al.

    Treatment of recalcitrant recurrent corneal erosions with inhibitors of matrix metalloproteinase–9, doxycycline and corticosteroids

    Am J Ophthalmol

    (2001)
  • J.A. Fogle et al.

    Tissue adhesive arrests stromal melting in the human cornea

    Am J Ophthalmol

    (1980)
  • C.S. Foster et al.

    Penetrating keratoplasty for herpes simplex keratitis

    Am J Ophthalmol

    (1981)
  • C.S. Foster et al.

    The immunopathology of Mooren’s ulcer

    Am J Ophthalmol

    (1979)
  • R.I. Fox

    Sjögren’s syndrome

    Lancet

    (2005)
  • S. Goto et al.

    Therapeutic keratoplasty using preserved corneas from keratoconus eyes

    Jpn J Ophthalmol

    (1999)
  • M.W. Grinstaff

    Designing hydrogel adhesives for corneal wound repair

    Biomaterials

    (2007)
  • K. Hanada et al.

    Multilayered amniotic membrane transplantation for severe ulceration of the cornea and sclera

    Am J Ophthalmol

    (2001)
  • L.W. Hirst et al.

    Cornea1 perforations: changing methods of treatment, 1960–1980

    Ophthalmology

    (1982)
  • M.S. Insler et al.

    Cornea1 ulceration following cataract surgery in patients with rheumatoid arthritis

    J Am Intraocul Implant Soc

    (1985)
  • H. Isawi et al.

    Corneal melting and perforation in Stevens Johnson syndrome following topical bromfenac use

    J Cataract Refract Surg

    (2007)
  • D.W. Killingsworth et al.

    Results of therapeutic penetrating keratoplasty

    Ophthalmology

    (1993)
  • H.R. Koch et al.

    Corneal penetration of fluoroquinolones: aqueous humor concentrations after topical application of levofloxacin 0.5% and ofloxacin 0.3% eyedrops

    J Cataract Refract Surg

    (2005)
  • R.P. Kowalski et al.

    Gatifloxacin and moxifloxacin: an in vitro susceptibility comparison to levofloxacin, ciprofloxacin, and ofloxacin using bacterial keratitis isolates

    Am J Ophthalmol

    (2003)
  • M. Küchle et al.

    Nonmechanical excimer laser penetrating keratoplasty for perforated or predescemetal corneal ulcers

    Ophthalmology

    (1999)
  • G.D. Kymionis et al.

    Corneal perforation after conductive keratoplasty with previous refractive surgery

    J Cataract Refract Surg

    (2003)
  • P. Lalitha et al.

    Risk factors for treatment outcome in fungal keratitis

    Ophthalmology

    (2006)
  • P.L. Mallari et al.

    Increased incidence of corneal perforation after topical fluoroquinolone treatment for microbial keratitis

    Am J Ophthalmol

    (2001)
  • F.B. Marangon et al.

    Ciprofloxacin and levofloxacin resistance among methicillin-sensitive Staphylococcus aureus isolates from keratitis and conjunctivitis

    Am J Ophthalmol

    (2004)
  • S.A. Melki et al.

    Late traumatic dislocation of laser in situ keratomileusis corneal flaps

    Ophthalmology

    (2000)
  • D. Meller et al.

    Amniotic membrane transplantation for acute chemical or thermal burns

    Ophthalmology

    (2000)
  • J.J. Arentsen et al.

    Management of cornea1 descemetoceles and perforations

    Ophthalmic Surg

    (1985)
  • R. Arora et al.

    Amniotic membrane transplantation in acute chemical burns

    Eye (Lond)

    (2005)
  • P.A. Asbell et al.

    Ocular TRUST: nationwide antimicrobial susceptibility patterns in ocular isolates

    Am J Ophthalmol

    (2008)
  • P. Batta et al.

    Severe pseudomonal keratitis in an infrequent daily disposable contact lens wearer

    Eye Contact Lens

    (2010)
  • D.A. Bessant et al.

    Lamellar keratoplasty in the management of inflammatory corneal ulceration and perforation

    Eye (Lond)

    (1994)
  • P.R. Bhatt et al.

    Therapeutic deep lamellar keratoplasty for corneal perforations

    Eye (Lond)

    (2007)
  • S.A. Boruchoff et al.

    Medical and surgical management of corneal thinnings and perforations

    Int Ophthalmol Clin

    (1975)
  • K. Brejchova et al.

    Matrix metalloproteinases in recurrent corneal melting associated with primary Sjörgen’s syndrome

    Mol Vis

    (2009)
  • P.I. Burgess et al.

    SmartPlug versus silicone punctal plug therapy for dry eye: a prospective randomized trial

    Cornea

    (2008)
  • F.R. Burns et al.

    Inhibition of alkali-induced corneal ulceration and perforation by a thiol peptide

    Invest Ophthalmol Vis Sci

    (1990)
  • F.R. Burns et al.

    Inhibition of purified collagenase from alkali-burned rabbit corneas

    Invest Ophthalmol Vis Sci

    (1989)
  • H.D. Cavanagh

    Herpetic ocular disease: therapy of persistent epithelial defects

    Int Ophthalmol Clin

    (1975)
  • W.L. Chen et al.

    Comparison of the bacteriostatic effects, corneal cytotoxicity, and the ability to seal corneal incisions among three different tissue adhesives

    Cornea

    (2007)
  • C.C. Chiang et al.

    Central corneal delle as a complication of erythema multiforme major

    Cornea

    (2007)
  • I. Claerhout et al.

    Cutting and pasting corneas: combination of a corneal allograft with relocation of a crescent of autologous corneal tissue in therapeutic penetrating keratoplasty

    Cornea

    (2006)
  • I. Claerhout et al.

    Therapeutic penetrating keratoplasty: clinical outcome and evolution of endothelial cell density

    Cornea

    (2002)
  • E.J. Cohen

    The case against the use of steroids in the treatment of bacterial keratitis

    Arch Ophthalmol

    (2009)
  • K.L. Cohen

    Sterile corneal perforation after cataract surgery in Sjögren’s syndrome

    Br J Ophthalmol

    (1982)
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