Major ReviewManagement of Corneal Perforation
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.
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