Management of corneal perforations: An update

Overview

This review, published in the Indian Journal of Ophthalmology in 2020, covers corneal perforation, a potentially devastating result of conditions that cause the cornea to melt. The causes are traumatic or non-traumatic. Non-traumatic causes include infections (bacterial, fungal, viral or parasitic) and non-infectious conditions such as severe dry eye and autoimmune disease. Prompt intervention is needed to restore the integrity of the eye and to prevent complications such as endophthalmitis, choroidal haemorrhage and glaucoma. The choice of treatment depends on the size, location and cause of the perforation, and several stages of treatment are often required.

Tissue adhesives

Synthetic adhesive glue suits small perforations away from the limbus. It is ideally applied in the operating theatre and covered with a bandage contact lens. It can also halt ongoing stromal melting. Its drawbacks include tissue toxicity, raised eye pressure and infection. Biological fibrin glue is less toxic and fully biodegradable, but it degrades faster and has no antibacterial effect. Modified techniques extend the use of glue to somewhat larger defects.

Tissue grafts

Conjunctival flaps support healing but add blood vessels to the cornea, which raises the risk of rejection if the eye later needs a transplant. Amniotic membrane, often applied in multiple layers, provides growth factors and reduces inflammation, and it is particularly useful for central perforations. A Tenon's patch graft uses the patient's own tissue. It can seal larger perforations where glue is unsuitable, with no rejection and no need for donor tissue.

Keratoplasty

Large perforations usually require tectonic keratoplasty using full-thickness, lamellar or patch grafts. Lamellar techniques are increasingly favoured because rejection is less frequent. In infectious keratitis, therapeutic keratoplasty also removes infected tissue. The review describes techniques that preserve the iris when it plugs the perforation, and approaches for sterile melts and peripheral perforations. It also covers the use of donor tissue left over from other corneal procedures.

Clinical implications

Smaller lesions can often be managed with adhesives, Tenon's patch grafts or amniotic membrane, while larger ones may need urgent keratoplasty. Bioengineered corneal tissue is being developed to address the shortage of donor corneas.