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Neurotrophic keratopathy is most commonly en-

countered after a viral infection, typically HSV and HZV,
as well as secondary to tumor, trauma, or surgery (e.g.,
penetrating keratoplasty, cataract extraction, LASIK). The
lack of corneal sensation leads to chronic epithelial break-
down with slow healing. This persistent epitheliopathy
makes the cornea susceptible to a sterile melting process or
infectious keratitis and potential perforation.
Corneal degenerations such as Terriens marginal
degeneration can lead to slow, progressive thinning, which
may rarely proceed to perforation. Corneal ectatic dis-
orders such as keratoconus, keratoglobus, or pellucid mar-
ginal degeneration may present with extreme thinning
and ectasia. Perforation in these situations is exceedingly
rare, but can occur as a result of minimal trauma, especially
in keratoglobus,
23
and has also been reported in pellucid
marginal degeneration.
24,25
Corneal rupture and stulization
after acute hydrops in keratoconus are also uncommon but
have been described.
26,27
Terminology
The terminology of corneal ulceration, descemetocele, and
perforation can be confusing and is often misunderstood.
It is important to clearly dene these terms. A corneal ulcer
refers to a defect in the epithelial layer with some degree of
stromal loss, often with inltration or necrosis (Fig. 137.1).
Descemetocele refers to a lesion in which there is destruc-
tion of the epithelium and stroma, with only Descemets
membrane and endothelium remaining (Fig. 137.2).
28
Because of its highly elastic nature and the intraocular
pressure, Descemets membrane often bulges anteriorly,
forming the classic dome-shaped, transparent membrane,
which is easily recognized at the slit lamp (Fig. 137.3). At
this stage, the cornea is in imminent danger of perforation.
A cornea that has thinned to the level of Descemets
membrane but contains an epithelialized surface is best
described as a healed descemetocele and is at much less
risk for further ulceration and perforation. The term
impending perforation is less specic, but typically refers to
any ulceration with severe stromal thinning that clinically
appears capable of perforating in the near future. Perforation
refers to a situation in which there is a denite full-
thickness defect in the cornea and there is communication
between the anterior chamber and surface of the eye. A
descemetocele through which aqueous is percolating is
technically a true perforation, but is often referred to as a
leaking descemetocele. Regardless of terminology, any non-
epithelialized, severe thinning of the cornea must be
treated as a therapeutic emergency that requires prompt
intervention.
Management of Corneal Perforations
CHAPTER 137
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Chapter 137
Management of Corneal Perforations
Marc A. Honig Christopher J. Rapuano
Section 1 Corneal Surgery
Corneal perforations can result from a variety of disorders
and can lead to devastating visual sequelae. Descemetoceles
and perforations are ophthalmic emergencies that require
immediate recognition and intervention. The primary
causes include infection, inflammation, and trauma. How-
ever, other conditions such as exposure and neurotrophic
keratopathy, xerosis, and corneal degenerations can also
cause ulceration and perforation (Box 137.1). Conditions
leading to descemetocele and perforation are briefly out-
lined here. The work-up and treatment of these disorders
are discussed at length elsewhere in this edition.
Management should be directed toward prevention of
corneal perforation, because once a perforation has occurred,
the visual outcome is often disappointing. Recognition of
the conditions leading to perforation and management
of the perforated cornea are discussed. Treatment of traumatic
perforations are not discussed in depth here because this
topic is covered in great detail in other chapters.
Etiology
The most common cause of corneal perforation is infec-
tion, either bacterial, fungal, or viral. Infection accounts for
between 24% and 55% of all perforations,
16
with bacterial
infections being most common.
2
A frequent predisposing
factor leading to these and other types of perforations is
early breakdown of the corneal epithelium. Once this barrier
is compromised, the pathogen gains easy access to the
stroma, inciting an inflammatory response in the host.
Damage results from a combination of direct microbial
invasion, and more importantly, through host chemotaxis
of leukocytes, causing collagenases to be released and
corneal ulceration to occur. Viral keratitis, namely herpes
simplex (HSV) and herpes zoster (HZV), may lead to corneal
perforation secondary to recurrent active ulcerative keratitis,
persistent epithelial defects, and neurotrophic keratopathy.
7
Fungal infections are less common and often progress more
slowly than other forms of infectious ulcerative keratitis,
but nonetheless may lead to corneal perforation.
Inflammatory conditions such as collagen vascular
diseases, acne rosacea, Wegeners granulomatosis, and
Moorens (idiopathic) ulcer can also cause peripheral, and
occasionally central, ulcerative keratitis and subsequent
perforation. The use of topical corticosteroids and topical
nonsteroidal anti-inflammatory drugs (NSAIDs),
810
may
exacerbate or initiate a stromal melt in the presence of
one of these disorders, but perforation can also occur
spontaneously.
11,12
Trauma, either chemical, thermal, surgical, or penetrating,
is also a common cause of corneal perforation. Chemical
injuries, alkali burns in particular, may cause devastating
corneal damage, initially by direct tissue destruction and
later by induction of stromal melting and necrosis because
of the elaboration of collagenases.
13
Thermal injury normally
causes supercial corneal damage but may, in rare instances,
cause perforation because of extreme heat or associated
mechanical injury.
14
Corneal ulceration and perforation
have also been reported after cataract extraction, both with
and without intraocular lens implantation,
15,16
LASIK,
17
PTK,
18
pterygium excision with use of mitomycin-C,
19,20
and rarely after argon laser photocoagulation.
21
Xerosis and exposure keratopathy are also causes of
corneal perforation.
7
Xerosis may be idiopathic; related to
collagen vascular disease (Sjogrens syndrome); or second-
ary to Stevens-Johnson syndrome, ocular cicatricial
pemphigoid, or vitamin A deciency. Exposure may result
from seventh nerve palsy, thyroid ophthalmopathy,
involutional ectropion, floppy eyelid syndrome,
22
or
chronic cicatrizing eyelid disorders.
Box 137.1
Conditions leading to corneal perforation
Infectious (bacterial, fungal, viral [herpes simplex, herpes zoster])
Inflammatory (collagen vascular disease, acne rosacea, atopic
disease, Wegeners granulomatosis, Moorens [idiopathic] ulcer)
Trauma (chemical, thermal, penetrating)
Xerosis (idiopathic, Sjgrens syndrome, Stevens-Johnson
syndrome, ocular cicatricial pemphigoid, vitamin A deciency)
Exposure (seventh nerve palsy, thyroid related ophthalmopathy,
ectropion, floppy eyelid syndrome)
Neurotrophic (postviral, tumor, trauma, postsurgical [cataract
extraction, penetrating keratoplasty])
Degeneration/ectasia (Terriens marginal degeneration,
keratoconus, keratoglobus, pellucid marginal degeneration)
Surgical (cataract extraction, LASIK, PRK, epithelial sparing PRK,
pterygium excision with mitomycin-C, glaucoma ltering/shunt
surgery)
Fig. 137.1 A, Peripheral
corneal ulcer (box) in a
patient with rheumatoid
arthritis. B, Slit lamp
view demonstrating
mild to moderate
corneal thinning and
stromal loss.
A B
Fig. 137.2 Small central descemetocele within a large corneal ulcer.
Note the slight bulge of Descemets membrane. The shallow anterior
chamber indicates that this descemetocele is leaking slightly.
P u p il

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Inflammatory conditions such as collagen vascular Inflammatory conditions such as collagen vascular
diseases, acne rosacea, Wegeners granulomatosis, and diseases, acne rosacea, Wegeners granulomatosis, and
Moorens (idiopathic) ulcer can also cause peripheral, and Moorens (idiopathic) ulcer can also cause peripheral, and
occasionally central, ulcerative keratitis and subsequent occasionally central, ulcerative keratitis and subsequent
perforation. The use of topical corticosteroids and topical perforation. The use of topical corticosteroids and topical
nonsteroidal anti-inflammatory drugs (NSAIDs), nonsteroidal anti-inflammatory drugs (NSAIDs),
exacerbate or initiate a stromal melt in the presence of exacerbate or initiate a stromal melt in the presence of
one of these disorders, but perforation can also occur one of these disorders, but perforation can also occur
rauma, either chemical, thermal, surgical, or penetrating, rauma, either chemical, thermal, surgical, or penetrating,
is also a common cause of corneal perforation. Chemical is also a common cause of corneal perforation. Chemical
injuries, alkali burns in particular, may cause devastating injuries, alkali burns in particular, may cause devastating
corneal damage, initially by direct tissue destruction and corneal damage, initially by direct tissue destruction and
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slowly than other forms of infectious ulcerative keratitis, slowly than other forms of infectious ulcerative keratitis,
Inflammatory conditions such as collagen vascular Inflammatory conditions such as collagen vascular
diseases, acne rosacea, Wegeners granulomatosis, and diseases, acne rosacea, Wegeners granulomatosis, and
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Neurotrophic keratopathy is most commonly en- Neurotrophic keratopathy is most commonly en- Neurotrophic keratopathy is most commonly en-
countered after a viral infection, typically HSV and HZV, countered after a viral infection, typically HSV and HZV, countered after a viral infection, typically HSV and HZV,
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exacerbate or initiate a stromal melt in the presence of exacerbate or initiate a stromal melt in the presence of
one of these disorders, but perforation can also occur one of these disorders, but perforation can also occur
rauma, either chemical, thermal, surgical, or penetrating, rauma, either chemical, thermal, surgical, or penetrating,
is also a common cause of corneal perforation. Chemical is also a common cause of corneal perforation. Chemical
injuries, alkali burns in particular, may cause devastating injuries, alkali burns in particular, may cause devastating
corneal damage, initially by direct tissue destruction and corneal damage, initially by direct tissue destruction and
later by induction of stromal melting and necrosis because later by induction of stromal melting and necrosis because
of the elaboration of collagenases. of the elaboration of collagenases.
13 13
Thermal injury normally Thermal injury normally
causes supercial corneal damage but may, in rare instances, causes supercial corneal damage but may, in rare instances,
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lack of corneal sensation leads to chronic epithelial break- lack of corneal sensation leads to chronic epithelial break- lack of corneal sensation leads to chronic epithelial break-
down with slow healing. This persistent epitheliopathy down with slow healing. This persistent epitheliopathy down with slow healing. This persistent epitheliopathy
makes the cornea susceptible to a sterile melting process or makes the cornea susceptible to a sterile melting process or makes the cornea susceptible to a sterile melting process or
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occasionally central, ulcerative keratitis and subsequent occasionally central, ulcerative keratitis and subsequent
perforation. The use of topical corticosteroids and topical perforation. The use of topical corticosteroids and topical
may may
exacerbate or initiate a stromal melt in the presence of exacerbate or initiate a stromal melt in the presence of exacerbate or initiate a stromal melt in the presence of exacerbate or initiate a stromal melt in the presence of exacerbate or initiate a stromal melt in the presence of
-

penetrating keratoplasty, cataract extraction, LASIK). The penetrating keratoplasty, cataract extraction, LASIK). The penetrating keratoplasty, cataract extraction, LASIK). The
lack of corneal sensation leads to chronic epithelial break- lack of corneal sensation leads to chronic epithelial break- lack of corneal sensation leads to chronic epithelial break-
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Neurotrophic keratopathy is most commonly en- Neurotrophic keratopathy is most commonly en- Neurotrophic keratopathy is most commonly en-
countered after a viral infection, typically HSV and HZV, countered after a viral infection, typically HSV and HZV, countered after a viral infection, typically HSV and HZV,
as well as secondary to tumor, trauma, or surgery (e.g., as well as secondary to tumor, trauma, or surgery (e.g., as well as secondary to tumor, trauma, or surgery (e.g.,
penetrating keratoplasty, cataract extraction, LASIK). The penetrating keratoplasty, cataract extraction, LASIK). The penetrating keratoplasty, cataract extraction, LASIK). The
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Preoperative Management
After a perforation is detected, the ophthalmologist must
then determine whether correction of the problem can be
accomplished as an inpatient or outpatient, whether it can
be performed at the bedside or slit lamp, or whether surgical
intervention in the operating room is warranted.
If surgical repair is denitely indicated, the patient
should not receive food or drink by mouth, and a deter-
mination should be made of the last time food or drink
was ingested. In the presence of infection, systemic intra-
venous antibiotics (e.g., cefazolin, intravenously every
8 hours, and gentamicin, 6mg/kg ideal body weight intra-
venously every 24 hours, assuming normal creatinine clear-
ance, or ceftazidime, 1g intravenously every 8 hours) are
administered beginning as soon as possible and continued
for at least 2472 hours. It is also generally agreed that all
perforated ulcers and descemetoceles thought to be
infectious in origin should be gently scraped or swabbed
and sent for Gram and Giemsa stains, as well as cultures
and sensitivities. If the perforation is thought to be sterile
or the patient cannot be admitted to the hospital, oral
ciprofloxacin (500mg by mouth, twice a day), levofloxacin
(500mg by mouth, once a day) or moxifloxacin (400mg
by mouth, once a day) may be used prophylactically as a
second choice to intravenous antibiotics. A plastic shield
should be placed over the eye; and manipulation on the
part of the patient, ophthalmologist, and nursing staff
should be kept to a minimum. In general if the anterior
chamber is flat, repair (regardless of method) should be
performed within the rst 24 to 48 hours to avoid per-
manent peripheral anterior synechiae and damage to the
cornea, lens, and posterior segment.
Treatment options
Tissue adhesives
Cyanoacrylate glue
Cyanoacrylate glue has been used since the late 1960s
when Webster et al
30
reported the repair of two perforated
ulcers with n-heptyl-2-cyanoacrylate. Since then, corneal
gluing has become an increasingly popular treatment
modality because of its high efcacy, relative ease of appli-
cation, and its ability to delay an otherwise emergent surgical
repair in the operating room. Hirst et al
2,31
reported a trend
toward a lower enucleation rate and better visual results in
perforations treated with corneal glue. When effective, the
application of corneal glue can immediately restore
structural integrity to the globe. In these situations,
penetrating keratoplasty or other more permanent pro-
cedures can be avoided or at least delayed until a time
when the eye is quiet, and surgical intervention has a
better chance of success.
Nobe et al
32
reported that, for both infectious and
traumatic perforations, corneal transplantation had a better
chance of remaining clear if keratoplasty could be delayed.
Complicating factors relating to penetrating keratoplasty
in the acute setting of perforation include synechia for-
mation, glaucoma, uveitis, and eventual graft rejection
and failure in these inflamed eyes.
33,34
The success rate of
corneal transplantation in terms of graft clarity is also poor
in patients with immunologic or ocular surface disorders.
The use of tissue adhesives in this setting, to delay or avoid
penetrating keratoplasty until the eye is less inflamed and
the ocular surface is healthier, can be invaluable.
Kenyon
5
and others
32
have emphasized the importance
of early application of corneal glue in any noninfected,
progressive thinning disorder before perforation. Not only
is the procedure much easier to perform on a nonperforated
eye, but tissue adhesive has been shown to arrest the
process of ulceration. In addition, Eiferman and Snyder
35
reported antibacterial activity of butyl-2-cyanoacrylate
against Gram-positive organisms. This antibacterial activity
may in part contribute to the success of tissue adhesives in
some infected ulcers. In these situations, prevention of
perforation with early gluing may be a key factor in a
favorable visual outcome.
Although the goal of tissue adhesive application is to
quickly restore the integrity of the globe, with the under-
standing that subsequent, more denitive therapy may be
needed, it is sometimes successful as a single permanent
procedure. Of all perforations and descemetoceles treated
with tissue adhesives, 33% to 44% required no additional
surgical intervention and healed with tissue adhesive
alone.
3,36
Penetrating or lamellar keratoplasty, however,
was required in 37% to 43% of cases, and 7% to 9% later
required enucleation or evisceration.
3,36
The resulting
visual outcome can be quite variable and depends on a
large number of complicating factors such as the under-
lying ocular disease, location and size of the perforation,
and visual acuity before perforation.
In our experience, tissue adhesive is best suited for
small, relatively central perforations 1 to 2mm or less in
diameter at the level of Descemets membrane, although
successful treatment of perforations up to 3mm has been
reported.
36
Cyanoacrylate adhesive works best in ulcer-
ations because they provide a concave surface as opposed
to bulging descemetoceles, which have a more convex
curvature. Depending on the location and conguration of
the ulcer, however, exceptions to these rules exist. Others
have found tissue adhesives more useful in peripheral
lesions.
4
In general, when in doubt, one has little to lose by
attempting corneal gluing before undertaking an emergent
surgical procedure. In peripheral ulcers, the glue is more
likely to dislodge than in a comparable central ulcer
primarily because the glue also covers an adjacent area of
conjunctiva that does not hold glue well. Not infrequently,
with both central and peripheral perforations, the glue
may become dislodged, causing shallowing of the anterior
chamber. Reapplication of glue may be necessary to restore
the integrity of the globe.
Despite lack of approval by the Food and Drug
Administration (FDA), Histoacryl blau D-3508 (Melsungen,
West Germany), isobutyl-2-cyanoacrylate, has been a
commonly used tissue adhesive for the cornea.
37,38
It has
been available in Canada, but not in the United States;
however, it is difcult to obtain at the present time.
Another polymer, n-butyl cyanoacrylate (Nexacryl, Tri
Signs and Symptoms of
Descemetocele and Perforation
The majority of patients with a leaking descemetocele or
corneal perforation experience an abrupt decrease in visual
acuity with associated pain; however, the clinical presen-
tation can be quite variable. Ulceration and perforation in
a previously healthy eye may cause the patient to notice
the acute onset of symptoms sooner than in a sick or
infected eye, which may already have poor visual acuity
and discomfort. Similarly, a neurotrophic eye may not
sense any change in symptoms, other than possibly a
change in visual acuity.
Painful symptoms may be attributable to ocular surface
disease or to deeper pain secondary to iris or ciliary spasm
or hemorrhagic choroidal detachments from rapid decom-
pression of the eye. Acute perforations may also cause a
sudden loss of aqueous, which the patient may simply
dismiss as excess tear production. Patients at high risk for
perforation should be made aware of the possible symp-
toms and told to seek immediate ophthalmic attention if
any of them occur. In eyes with extremely thinned corneas,
wearing a plastic shield or glasses during the day and
shield at bedtime should be recommended.
The ophthalmologist examining a patient with a sus-
pected descemetocele or perforation must treat the situation
similar to that of an open globe from other causes. The
patient should be discouraged from squeezing during the
examination, and minimal manipulation of the globe and
minimal application of topical medications should be
performed. A careful medical and ophthalmic history
should be obtained to help determine the etiology of the
perforation.
The most common signs of corneal perforation are a flat
or shallow anterior chamber, positive Seidel test, and uveal
prolapse. For the Seidel test, we prefer the use of a sterile
fluorescein strip saturated with a small amount of sterile
saline to paint the suspected area of perforation. The
presence of clearing or dilution of fluorescein dye under
slit lamp examination with the cobalt blue lter is evi-
dence of a denite perforation. Examination may reveal an
obvious perforation with the above signs; however, in many
situations, signs of perforation may be more subtle. Uveal
prolapse may plug a wound causing re-formation of the
anterior chamber and a negative Seidel test. Applying gentle
pressure from above or below often may yield a positive
Seidel sign, which is not present without any external
manipulation. If the anterior chamber is completely flat,
the Seidel test is often negative, even in the presence of a
frank perforation. These characteristics are summarized in
Box 137.2.
Infectious ulcers with a signicant amount of purulent
material and mucus can be difcult to evaluate for a
perforation. If a central clear zone exists within a large,
dense inltrate, a perforation or descemetocele should be
suspected. Any shallowing of the anterior chamber on
sequential examinations in the absence of high intraocular
pressure and pupillary block is presumptive evidence of
perforation. The presence of a hypopyon that suddenly
clears on subsequent reexamination should also raise ones
suspicion that a perforation has occurred. In an impending
perforation, the only sign may be radiating folds in
Descemets membrane emanating from the base of the
ulcer.
29
This sign may be particularly helpful in cases in
which the inltrate and necrotic stroma obscure the view.
An intact epithelium does not imply that a corneal per-
foration has not occurred. Chronic perforations with uvea
or other material plugging the wound can reepithelialize
spontaneously. These cases often require intervention;
however, because the epithelium provides a moderately
effective barrier to infection, repair can be performed on
an urgent rather than emergent basis. After a suspected
perforation is conrmed at the bedside or slit lamp, atten-
tion should then be directed to repair and restoration of
the integrity of the globe as soon as possible.
Management of Corneal Perforations
CHAPTER 137
Section 1: Corneal Surgery
PART X: THERAPEUTIC AND RECONSTRUCTIVE PROCEDURES
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Fig. 137.3 Large area of iris prolapse covered with smooth,
glistening intact Descemets membrane in this eye with chronic
corneal edema.
Box 137.2
Signs and symptoms of perforation and descemetocele
Symptoms
Pain
Decreased visual acuity
Increased tearing
Signs
Shallow or flat anterior chamber (perforation)
Positive Seidel test (perforation)
Uveal tissue to the posterior cornea or frank prolapse
(perforation)
Central clear zone (often bulging) within area of inltrate or
thinning (descemetocele)
Radiating folds in Descemets membrane emanating from the
base of the ulceration (descemetocele)

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An intact epithelium does not imply that a corneal per- An intact epithelium does not imply that a corneal per- An intact epithelium does not imply that a corneal per-
foration has not occurred. Chronic perforations with uvea foration has not occurred. Chronic perforations with uvea foration has not occurred. Chronic perforations with uvea
or other material plugging the wound can reepithelialize or other material plugging the wound can reepithelialize or other material plugging the wound can reepithelialize
spontaneously. These cases often require intervention; spontaneously. These cases often require intervention; spontaneously. These cases often require intervention;
however, because the epithelium provides a moderately however, because the epithelium provides a moderately however, because the epithelium provides a moderately
effective barrier to infection, repair can be performed on effective barrier to infection, repair can be performed on effective barrier to infection, repair can be performed on
an urgent rather than emergent basis. After a suspected an urgent rather than emergent basis. After a suspected an urgent rather than emergent basis. After a suspected
perforation is conrmed at the bedside or slit lamp, atten- perforation is conrmed at the bedside or slit lamp, atten- perforation is conrmed at the bedside or slit lamp, atten-
tion should then be directed to repair and restoration of tion should then be directed to repair and restoration of tion should then be directed to repair and restoration of
the integrity of the globe as soon as possible. the integrity of the globe as soon as possible. the integrity of the globe as soon as possible.
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Descemets membrane emanating from the base of the Descemets membrane emanating from the base of the Descemets membrane emanating from the base of the
This sign may be particularly helpful in cases in This sign may be particularly helpful in cases in This sign may be particularly helpful in cases in
which the inltrate and necrotic stroma obscure the view. which the inltrate and necrotic stroma obscure the view. which the inltrate and necrotic stroma obscure the view.
An intact epithelium does not imply that a corneal per- An intact epithelium does not imply that a corneal per- An intact epithelium does not imply that a corneal per-
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perforated ulcers and descemetoceles thought to be perforated ulcers and descemetoceles thought to be perforated ulcers and descemetoceles thought to be
infectious in origin should be gently scraped or swabbed infectious in origin should be gently scraped or swabbed infectious in origin should be gently scraped or swabbed
and sent for Gram and Giemsa stains, as well as cultures and sent for Gram and Giemsa stains, as well as cultures and sent for Gram and Giemsa stains, as well as cultures
and sensitivities. If the perforation is thought to be sterile and sensitivities. If the perforation is thought to be sterile and sensitivities. If the perforation is thought to be sterile
or the patient cannot be admitted to the hospital, oral or the patient cannot be admitted to the hospital, oral or the patient cannot be admitted to the hospital, oral
ciprofloxacin (500mg by mouth, twice a day), levofloxacin ciprofloxacin (500mg by mouth, twice a day), levofloxacin ciprofloxacin (500mg by mouth, twice a day), levofloxacin
(500mg by mouth, once a day) or moxifloxacin (400mg (500mg by mouth, once a day) or moxifloxacin (400mg (500mg by mouth, once a day) or moxifloxacin (400mg
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effective barrier to infection, repair can be performed on effective barrier to infection, repair can be performed on effective barrier to infection, repair can be performed on
an urgent rather than emergent basis. After a suspected an urgent rather than emergent basis. After a suspected an urgent rather than emergent basis. After a suspected
perforation is conrmed at the bedside or slit lamp, atten- perforation is conrmed at the bedside or slit lamp, atten- perforation is conrmed at the bedside or slit lamp, atten-
tion should then be directed to repair and restoration of tion should then be directed to repair and restoration of tion should then be directed to repair and restoration of
the integrity of the globe as soon as possible. the integrity of the globe as soon as possible. the integrity of the globe as soon as possible.
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should be placed over the eye; and manipulation on the should be placed over the eye; and manipulation on the should be placed over the eye; and manipulation on the
part of the patient, ophthalmologist, and nursing staff part of the patient, ophthalmologist, and nursing staff part of the patient, ophthalmologist, and nursing staff
should be kept to a minimum. In general if the anterior should be kept to a minimum. In general if the anterior should be kept to a minimum. In general if the anterior
or other material plugging the wound can reepithelialize or other material plugging the wound can reepithelialize or other material plugging the wound can reepithelialize
spontaneously. These cases often require intervention; spontaneously. These cases often require intervention; spontaneously. These cases often require intervention;
however, because the epithelium provides a moderately however, because the epithelium provides a moderately however, because the epithelium provides a moderately
effective barrier to infection, repair can be performed on effective barrier to infection, repair can be performed on effective barrier to infection, repair can be performed on
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second choice to intravenous antibiotics. A plastic shield second choice to intravenous antibiotics. A plastic shield second choice to intravenous antibiotics. A plastic shield
should be placed over the eye; and manipulation on the should be placed over the eye; and manipulation on the should be placed over the eye; and manipulation on the
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and sensitivities. If the perforation is thought to be sterile and sensitivities. If the perforation is thought to be sterile and sensitivities. If the perforation is thought to be sterile
or the patient cannot be admitted to the hospital, oral or the patient cannot be admitted to the hospital, oral or the patient cannot be admitted to the hospital, oral
ciprofloxacin (500mg by mouth, twice a day), levofloxacin ciprofloxacin (500mg by mouth, twice a day), levofloxacin ciprofloxacin (500mg by mouth, twice a day), levofloxacin
(500mg by mouth, once a day) or moxifloxacin (400mg (500mg by mouth, once a day) or moxifloxacin (400mg (500mg by mouth, once a day) or moxifloxacin (400mg
by mouth, once a day) may be used prophylactically as a by mouth, once a day) may be used prophylactically as a by mouth, once a day) may be used prophylactically as a
second choice to intravenous antibiotics. A plastic shield second choice to intravenous antibiotics. A plastic shield second choice to intravenous antibiotics. A plastic shield
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ance, or ceftazidime, 1g intravenously every 8 hours) are ance, or ceftazidime, 1g intravenously every 8 hours) are ance, or ceftazidime, 1g intravenously every 8 hours) are
administered beginning as soon as possible and continued administered beginning as soon as possible and continued administered beginning as soon as possible and continued
for at least 2472 hours. It is also generally agreed that all for at least 2472 hours. It is also generally agreed that all for at least 2472 hours. It is also generally agreed that all
perforated ulcers and descemetoceles thought to be perforated ulcers and descemetoceles thought to be perforated ulcers and descemetoceles thought to be
infectious in origin should be gently scraped or swabbed infectious in origin should be gently scraped or swabbed infectious in origin should be gently scraped or swabbed
and sent for Gram and Giemsa stains, as well as cultures and sent for Gram and Giemsa stains, as well as cultures and sent for Gram and Giemsa stains, as well as cultures
and sensitivities. If the perforation is thought to be sterile and sensitivities. If the perforation is thought to be sterile and sensitivities. If the perforation is thought to be sterile
Careful slit lamp examination and drawings should be
performed before the application of any tissue adhesive,
because after gluing and placement of a bandage soft
contact lens, subsequent examination of the perforation
site may be difcult. Particular attention should be focused
on the size and extent of the perforation, as well as the
status of the lens and the presence of uveal prolapse.
During the application of the glue, we prefer to use an
operating microscope in the ofce or minor surgery room
with the patient in the supine position. This technique
allows better control of the patients head and permits
gravity to work in the ophthalmologists favor. If this
technique is not possible, application can be performed at
the slit lamp or at the bedside. Although the procedure
often cannot be performed with strict sterile technique,
care should be taken to keep the eld as aseptic as possible.
A fenestrated plastic drape works well.
On a side table, the tissue adhesive is opened and placed
alongside sterile cotton-tipped applicators and cellulose
spears (e.g., Weck-cel sponges, Edward Weck Inc., NC). The
wooden part of the cotton-tipped applicator is then broken
in half so that an angled and tapered edge is obtained. If a
jagged edge remains it can be trimmed. A small ring of any
sterile ophthalmic ointment (e.g., erythromycin) is placed
approximately 1 to 2mm from the broken edge of the
applicator (Fig. 137.5A). When a small amount of glue is
required for small perforations, the ointment is placed
closer to the tip, and vice versa for larger perforations.
Attention is then redirected to the operating micro-
scope. Several drops of topical anesthetic are placed in
Point Medical L.P., Raleigh, NC) had been used experi-
mentally at several centers with good success; however, it
has never been FDA approved for ophthalmic use.
36
Recent
clinical success has been reported using another polymer,
2-octyl-cyanoacrylate.
39
This adhesive, with the trade
name, Dermabond (Ethicon Inc., Summerville, NJ), is
commercially available and is FDA approved as a skin
adhesive. It is conveniently packaged in individual ampules
and is being used at several academic centers where
Histoacryl is no longer available. Anecdotally, others have
described success using dental glue, Isodent (Ellman Inc.,
Hewlett, NY) to treat corneal perforations. Commercial
super glue, methyl-2-cyanoacrylate, appears to be more
toxic to the cornea than the adhesives mentioned
previously.
40,41
Despite its easy availability and anecdotal
experience with this polymer, super glue is not currently
recommended for ophthalmic use. A biologic glue (Tisseel,
Immuno France, France) composed of brin has been used
with some success.
42
It appears to have all of the advan-
tages of cyanoacrylate glue and is degraded physiologically;
however, it is not commonly used in the United States. Both
cyanoacrylate
43
and Human Fibrin Glue
44
(HFG, Tisseel,
Baxter, Deereld, IL, USA or Tissucol, Baxter, Belgium) have
been used in conjunction with amniotic membrane trans-
plantation (AMT), a technique which will be discussed
later in this chapter.
Method of application
Many techniques for application of tissue adhesives have
been described, all of which rely on the same basic principles
but vary in the instruments or applicators used to apply
the adhesive in a delicate, controlled fashion. The common
goal is to plug the perforation with the smallest amount of
glue possible to minimize excess glue protruding from the
surface or on the adjacent normal cornea. We describe in
detail one method and later list modications that also
exist (Fig. 137.4). Box 137.3 lists the equipment necessary
to perform corneal gluing in the ofce or at the bedside.
Management of Corneal Perforations
CHAPTER 137
Section 1: Corneal Surgery
PART X: THERAPEUTIC AND RECONSTRUCTIVE PROCEDURES
Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages
Fig. 137.4 Tissue adhesive application. A, Small midperipheral
full-thickness perforated corneal ulcer in a patient with acne rosacea
keratitis. B, Slit lamp view demonstrates a flat anterior chamber.
C, Perforation treated with cyanoacrylate tissue adhesive and a
bandage soft contact lens. D, Slit lamp view 1 hour after placement of
tissue glue demonstrating re-formation of the anterior chamber (AC).
C
A
D
A C
G lu e
B
I ris
Box 137.3
Equipment needed for application of tissue adhesive
Slit lamp or operating microscope
Barraquer eyelid speculum
Tissue adhesive
Cellulose spears
Sterile drape (if available)
Bandage soft contact lens
Preservative-free articial tears
Cotton-tipped applicators
Ophthalmic ointment
Topical anesthetic drops
Balanced salt solution
Jewelers forceps
Viscoelastic substance
Fig. 137.5 Technique for application of
cyanoacrylate tissue adhesive. A, Sterile
wooden applicator (1) with a broken,
tapered, smooth end and a ring of
ophthalmic ointment (2) placed
approximately 1 mm from the edge. A small
drop of tissue adhesive (3) is placed on the
end of the applicator; the amount is limited
by the ointment. The placement of the ring of
ointment can be modied to control the
amount of tissue adhesive that will be
delivered to the wound. B, The patient is
lying in a supine position under the operating
microscope with the eyelid speculum in place.
The perforation site (1) and the surrounding
1 to 2 mm have been debrided of epithelium
and necrotic debris. The surgeon has a
cellulose spear (2) in one hand and the
wooden applicator with the tissue adhesive
(3) in the other.
A
1
3
1
2
2 3
B

P
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O
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P
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O
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G lu e G lu e
O
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O
F

O
F

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Careful slit lamp examination and drawings should be Careful slit lamp examination and drawings should be Careful slit lamp examination and drawings should be
performed before the application of any tissue adhesive, performed before the application of any tissue adhesive, performed before the application of any tissue adhesive,
because after gluing and placement of a bandage soft because after gluing and placement of a bandage soft because after gluing and placement of a bandage soft
E
L
S
E
V
I
E
R

E
L
S
E
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E
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iscoelastic substance iscoelastic substance
E
L
S
E
V
I
E
R

E
L
S
E
V
I
E
R

C
O
N
T
E
N
T

C
O
N
T
E
N
T

C
O
N
T
E
N
T

C
O
N
T
E
N
T

C
O
N
T
E
N
T

C
O
N
T
E
N
T

-

site may be difcult. Particular attention should be focused site may be difcult. Particular attention should be focused site may be difcult. Particular attention should be focused
-

N
O
T
Careful slit lamp examination and drawings should be Careful slit lamp examination and drawings should be Careful slit lamp examination and drawings should be
performed before the application of any tissue adhesive, performed before the application of any tissue adhesive, performed before the application of any tissue adhesive,
because after gluing and placement of a bandage soft because after gluing and placement of a bandage soft because after gluing and placement of a bandage soft
contact lens, subsequent examination of the perforation contact lens, subsequent examination of the perforation contact lens, subsequent examination of the perforation
site may be difcult. Particular attention should be focused site may be difcult. Particular attention should be focused site may be difcult. Particular attention should be focused
N
O
T

F
I
N
A
L
F
I
N
A
L
F
I
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A
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F
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the previous glue until the entire defect is covered. There
are several alternative techniques for application of the
tissue adhesive. All attempt to provide a controlled method
for placement of the minimum amount of glue necessary
to close the perforation site. Several other methods are
described briefly. This list is by no means exhaustive, and
each practitioner may adopt his or her own modications
based on personal experience.
Ophthalmic ointment may be applied to the flat end of
a wooden applicator with a drop of adhesive placed on the
layer of ointment. The glue is then directly applied to the
perforation site and quickly removed. Alternatively, a poly-
ethylene disk (2 to 4mm in diameter) can be attached by
ointment to the flat end of a wooden applicator with glue
applied to the disk.
45,47,48
Both the glue and disk are then
directly applied to the defect with mild pressure. Fluid
may be applied to the area to expedite polymerization. The
applicator is then removed, with the disk in place. The disk
may be removed gently with forceps or simply left in place.
This method has the advantage of creating a smoother
surface than with other techniques. However, a contact lens
is still necessary for comfort. Similar variations include a
circular piece of a dry collagen shield, plastic surgical drape,
or collagen minishield (Bio Cor, Bausch and Lomb,
Clearwater, FL) in lieu of a polyethylene disk.
38
By apply-
ing gentle pressure during application, this method allows
both adhesive and disk to be applied to the depth of the
defect because the disk is flexible. These methods may be
particularly helpful in descemetoceles in which the surface
to be glued has a convex anterior surface. The advantage
of a collagen shield is that it dissolves within 24 hours,
leaving a relatively smooth anterior surface to the tissue
adhesive plug.
The tip of the plastic handle from a cellulose spear
(either flat or cut at an angle), a metal spatula,
49
or the
needle from a tuberculin syringe
3,36
can be used as an
applicator. Because the latter two applicators are made of
metal, polymerization of adhesive to the metallic surface
may be a problem. A ne-gauge capillary tube provides an
effective way to control the amount of glue placed on the
eye. Unfortunately, these tubes are no longer commonly
available in the United States. Alternatively, the rubber
sleeve of an 18-gauge IV needle can be used to nely
control the application of glue. An angled polyethylene
pipette used in dentistry called the Squeez-ett (Ellman
Inc., Hewlett, NY) has been described as a superior method
for application of tissue adhesive.
40
Biologic glues (e.g. brin glues) have been used outside
of ophthalmology for several years and have recently been
proposed for use on the corneal surface. These glues have
several potential advantages. They tend not to solidify as
quickly as cyanoacrylate glue, likely making application
easier and more accurate. Additionally, they are softer and
smoother than cyanoacrylate glue and tend to cause less
discomfort and fewer symptoms. Potential disadvantages
include the unknown length of time they remain in place,
the promotion of microbial growth, and the potential
for transmission of disease as these glues are made from
human and animal products.
In larger perforations, a half-thickness corneal or scleral
patch
50
or collagen shield can be fashioned and t into
the debrided bed of the perforation or descemetocele. This
patch is then sealed in place with tissue adhesive, using
any of the aforementioned applicators. This technique has
the advantage of being able to seal relatively large per-
forations, limiting the chance that adhesive will enter the
anterior chamber (Fig. 137.6).
Postoperative management
All patients should be placed on aqueous suppressants
consisting of either a topical beta blocker (e.g., timolol
0.5% twice a day) and/or an oral carbonic anhydrase
inhibitor (e.g., acetazolamide 500mg sequel twice a day
or methazolamide 50mg three times a day) if medically
tolerable. This regimen decreases the pressure head against
the perforation. If the ulcer is thought to be noninfectious,
prophylactic broad-spectrum topical antibiotics such as
trimethoprim/polymyxin B, levofloxacin, gatifloxacin or
moxifloxacin should be used three to four times a day.
A protective shield or glasses should be placed on the eye
at all times. Preservative-free articial tears should be used
at least four to eight times a day to provide additional
lubrication and prevent the contact lens from becoming
dehydrated and tight. Severely dry eyes may require
punctal occlusion in the acute setting or at a later time
when the eye is more stable.
The need for hospital admission and the use of intra-
venous antibiotics in the case of a sterile perforation is
controversial. If we are concerned about infection we
generally admit patients and initiate intravenous anti-
biotics (e.g., cefazolin and gentamicin or ceftazidime) at
standard systemic doses for at least 4872 hours. If the
the affected and unaffected eyes, and a Barraquer eyelid
speculum is gently inserted. The perforation site is inspected
and debridement of any loose or necrotic material is
performed. In addition, it is extremely important to debride
1 to 2mm of epithelium surrounding the ulcer with a
cellulose spear or forceps, because glue does not adhere
well to epithelium. Any lens material, vitreous, or foreign
matter present should be removed. After debridement, the
perforation site should be dried thoroughly with success-
ively applied cellulose spears (Fig. 137.5B).
If the wound is not completely dry, the likelihood of a
satisfactory adhesion is greatly diminished. If the perfor-
ation site is actively leaking aqueous, several cellulose
spears may be necessary to dry the area completely. In
certain situations, if not contraindicated, the anterior
chamber may be gently massaged to express some aqueous
so that with successive attempts at drying, aqueous does
not immediately leak into the area to be glued.
45
If the anterior chamber is totally flat and iris or lens
is directly beneath the perforation, a small amount of
viscoelastic or air may be injected in an attempt to avoid
incarceration of the tissue into the glue or additional
damage to underlying structures.
46
This step is difcult to
achieve, especially with a flat chamber, and is not always
necessary. Incarceration of tissue into the adhesive is often
unavoidable and is not deemed a signicant detriment to
the ultimate success of the procedure.
One small drop of tissue adhesive is then carefully
applied to the prepared end of the wooden applicator (Fig.
137.5A). With the glue in one hand and a cellulose spear
in the other, the area to be glued is quickly dried with the
tip of the spear, and the glue is then immediately applied
(Fig. 137.5C). This maneuver is accomplished by gently
touching the tip with the glue directly to the perforation
site and then removing it quickly. The cellulose spear
should not be applied near the glued area until the
adhesive has totally dried because it will stick to the glue.
The glue will solidify completely within several minutes.
The polymerization process can be expedited by applying
a few drops of fluid (e.g., proparacaine or preservative-free
articial tears) to the surface, but one must be careful not
to displace wet glue with fluid. The goal is to ll the
ulcerated area with a minimal amount of glue. The ideal
amount is just enough to secure it to the surrounding
cornea without creating a large ring or mound of glue. Too
much glue or excessive anterior protrusion of glue, which
may cause discomfort even with a bandage contact lens, is
undesirable.
If the entire defect is not covered or a small leak remains,
additional applications of tissue adhesive to the existing
plug or to an adjacent area may be necessary. If the wound
is still leaking and the existing plug is unsatisfactory, the
glue can be removed by gently rotating it at the corneal
surface and then lifting it away from the cornea. Gluing
may be reattempted, but repeated application and removal
of glue may create or enlarge the defect.
After the adhesive solidies, the area should be dried
carefully with a cellulose spear and reinspected for an
aqueous leak. If too generous an amount of glue has been
applied, any excess glue that may have become adherent
to adjacent normal epithelialized cornea can occasionally
be removed carefully with a jewelers forceps. However, this
maneuver risks dislodging the entire plug. One additional
recheck of the glued area is recommended before a bandage
soft contact lens is applied. We use a loose tting, flat, low
power, low water content disposable extended wear soft
contact lens such as a Optima FW, base curve 9.0mm
(Bausch and Lomb, Rochester, NY). If this particular lens is
not available, any low water content extended wear soft
contact lens with the flattest (i.e., highest) base curve can
be used. Unlike soft contact lenses used for other purposes,
these lenses will not move signicantly with blinking after
gluing and may have large folds with edge off because of
surface irregularities caused by the tissue adhesive.
After placement of the bandage contact lens, the eyelid
speculum is gently removed from the eye. Depending on
the clinical setting, one may see reformation of the anterior
chamber before completion of the entire procedure
(Fig. 137.5D). The patient should be reexamined several
minutes later to check for formation of the anterior
chamber and for possible dislodging of the glue or contact
lens. If the glue and contact lens remain in place at the
initial examination after the procedure, the patient should
be rechecked 30 to 60 minutes later and once again within
the next 24 hours.
Small linear or curvilinear perforations may be sealed
using a modication of the method described. First, glue is
applied centrally, with subsequent applications adjacent to
Management of Corneal Perforations
CHAPTER 137
Section 1: Corneal Surgery
PART X: THERAPEUTIC AND RECONSTRUCTIVE PROCEDURES
Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages
Fig. 137.5 (Cont.) C, The perforation site is dried with successively
applied cellulose spears just before the application of the tissue
adhesive. As the glue is applied to the wound, the cellulose spear and
applicator are quickly removed. D, After successful application of
tissue adhesive (1), the perforation site is sealed. A bandage soft
contact lens (2) is in place and the anterior chamber is re-forming.
D
C
2
1
Fig. 137.6 Cyanoacrylate tissue adhesive placed in a 3 mm
perforation. Note the barbell shape of the glue with a large portion
in the anterior chamber (glue). In large perforations, this problem can
be avoided by placing a small piece of collagen shield or corneal tissue
in the base of the perforation before gluing to prevent the glue from
entering the anterior chamber.
G lu e

P
R
O
P
E
R
T
Y

applied, any excess glue that may have become adherent applied, any excess glue that may have become adherent applied, any excess glue that may have become adherent
to adjacent normal epithelialized cornea can occasionally to adjacent normal epithelialized cornea can occasionally to adjacent normal epithelialized cornea can occasionally
be removed carefully with a jewelers forceps. However, this be removed carefully with a jewelers forceps. However, this be removed carefully with a jewelers forceps. However, this
maneuver risks dislodging the entire plug. One additional maneuver risks dislodging the entire plug. One additional maneuver risks dislodging the entire plug. One additional
recheck of the glued area is recommended before a bandage recheck of the glued area is recommended before a bandage recheck of the glued area is recommended before a bandage
soft contact lens is applied. We use a loose tting, flat, low soft contact lens is applied. We use a loose tting, flat, low soft contact lens is applied. We use a loose tting, flat, low
power, low water content disposable extended wear soft power, low water content disposable extended wear soft power, low water content disposable extended wear soft
contact lens such as a Optima FW, base curve 9.0mm contact lens such as a Optima FW, base curve 9.0mm contact lens such as a Optima FW, base curve 9.0mm
(Bausch and Lomb, Rochester, NY). If this particular lens is (Bausch and Lomb, Rochester, NY). If this particular lens is (Bausch and Lomb, Rochester, NY). If this particular lens is
not available, any low water content extended wear soft not available, any low water content extended wear soft not available, any low water content extended wear soft
contact lens with the flattest (i.e., highest) base curve can contact lens with the flattest (i.e., highest) base curve can contact lens with the flattest (i.e., highest) base curve can
be used. Unlike soft contact lenses used for other purposes, be used. Unlike soft contact lenses used for other purposes, be used. Unlike soft contact lenses used for other purposes,
O
F

carefully with a cellulose spear and reinspected for an carefully with a cellulose spear and reinspected for an carefully with a cellulose spear and reinspected for an
aqueous leak. If too generous an amount of glue has been aqueous leak. If too generous an amount of glue has been aqueous leak. If too generous an amount of glue has been
applied, any excess glue that may have become adherent applied, any excess glue that may have become adherent applied, any excess glue that may have become adherent
E
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may be applied to the area to expedite polymerization. The may be applied to the area to expedite polymerization. The may be applied to the area to expedite polymerization. The
applicator is then removed, with the disk in place. The disk applicator is then removed, with the disk in place. The disk applicator is then removed, with the disk in place. The disk
may be removed gently with forceps or simply left in place. may be removed gently with forceps or simply left in place. may be removed gently with forceps or simply left in place.
This method has the advantage of creating a smoother This method has the advantage of creating a smoother This method has the advantage of creating a smoother
surface than with other techniques. However, a contact lens surface than with other techniques. However, a contact lens surface than with other techniques. However, a contact lens
is still necessary for comfort. Similar variations include a is still necessary for comfort. Similar variations include a is still necessary for comfort. Similar variations include a
circular piece of a dry collagen shield, plastic surgical drape, circular piece of a dry collagen shield, plastic surgical drape, circular piece of a dry collagen shield, plastic surgical drape,
S
A
M
P
L
E

soft contact lens is applied. We use a loose tting, flat, low soft contact lens is applied. We use a loose tting, flat, low soft contact lens is applied. We use a loose tting, flat, low
power, low water content disposable extended wear soft power, low water content disposable extended wear soft power, low water content disposable extended wear soft
contact lens such as a Optima FW, base curve 9.0mm contact lens such as a Optima FW, base curve 9.0mm contact lens such as a Optima FW, base curve 9.0mm
(Bausch and Lomb, Rochester, NY). If this particular lens is (Bausch and Lomb, Rochester, NY). If this particular lens is (Bausch and Lomb, Rochester, NY). If this particular lens is
not available, any low water content extended wear soft not available, any low water content extended wear soft not available, any low water content extended wear soft
contact lens with the flattest (i.e., highest) base curve can contact lens with the flattest (i.e., highest) base curve can contact lens with the flattest (i.e., highest) base curve can
be used. Unlike soft contact lenses used for other purposes, be used. Unlike soft contact lenses used for other purposes, be used. Unlike soft contact lenses used for other purposes,
these lenses will not move signicantly with blinking after these lenses will not move signicantly with blinking after these lenses will not move signicantly with blinking after
folds with edge off because of folds with edge off because of folds with edge off because of
the tissue adhesive. the tissue adhesive. the tissue adhesive.
C
O
N
T
E
N
T

ing gentle pressure during application, this method allows ing gentle pressure during application, this method allows ing gentle pressure during application, this method allows
both adhesive and disk to be applied to the depth of the both adhesive and disk to be applied to the depth of the both adhesive and disk to be applied to the depth of the
defect because the disk is flexible. These methods may be defect because the disk is flexible. These methods may be defect because the disk is flexible. These methods may be
be removed carefully with a jewelers forceps. However, this be removed carefully with a jewelers forceps. However, this be removed carefully with a jewelers forceps. However, this
maneuver risks dislodging the entire plug. One additional maneuver risks dislodging the entire plug. One additional maneuver risks dislodging the entire plug. One additional
recheck of the glued area is recommended before a bandage recheck of the glued area is recommended before a bandage recheck of the glued area is recommended before a bandage
soft contact lens is applied. We use a loose tting, flat, low soft contact lens is applied. We use a loose tting, flat, low soft contact lens is applied. We use a loose tting, flat, low
-

Clearwater, FL) in lieu of a polyethylene disk. Clearwater, FL) in lieu of a polyethylene disk. Clearwater, FL) in lieu of a polyethylene disk.
ing gentle pressure during application, this method allows ing gentle pressure during application, this method allows ing gentle pressure during application, this method allows
N
O
T

This method has the advantage of creating a smoother This method has the advantage of creating a smoother This method has the advantage of creating a smoother
surface than with other techniques. However, a contact lens surface than with other techniques. However, a contact lens surface than with other techniques. However, a contact lens
is still necessary for comfort. Similar variations include a is still necessary for comfort. Similar variations include a is still necessary for comfort. Similar variations include a
circular piece of a dry collagen shield, plastic surgical drape, circular piece of a dry collagen shield, plastic surgical drape, circular piece of a dry collagen shield, plastic surgical drape,
or collagen minishield (Bio Cor, Bausch and Lomb, or collagen minishield (Bio Cor, Bausch and Lomb, or collagen minishield (Bio Cor, Bausch and Lomb,
Clearwater, FL) in lieu of a polyethylene disk. Clearwater, FL) in lieu of a polyethylene disk. Clearwater, FL) in lieu of a polyethylene disk.
F
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ointment to the flat end of a wooden applicator with glue ointment to the flat end of a wooden applicator with glue ointment to the flat end of a wooden applicator with glue
Both the glue and disk are then Both the glue and disk are then Both the glue and disk are then
directly applied to the defect with mild pressure. Fluid directly applied to the defect with mild pressure. Fluid directly applied to the defect with mild pressure. Fluid
may be applied to the area to expedite polymerization. The may be applied to the area to expedite polymerization. The may be applied to the area to expedite polymerization. The
applicator is then removed, with the disk in place. The disk applicator is then removed, with the disk in place. The disk applicator is then removed, with the disk in place. The disk
may be removed gently with forceps or simply left in place. may be removed gently with forceps or simply left in place. may be removed gently with forceps or simply left in place.
This method has the advantage of creating a smoother This method has the advantage of creating a smoother This method has the advantage of creating a smoother
6.0 and 11.0mm,
32,54
with 7.5 to 8.0mm being optimal.
The donor is generally oversized by 0.50mm. Graft
centration can be problematic. Ideally, the graft edge and
sutures are kept out of the visual axis. Viscoelastic is
occasionally helpful in reinflating the anterior chamber
before trephination and also in maintaining tissue planes.
The method of trephination in the recipient is quite
variable. In general, trephination is difcult to achieve in
a soft eye. The standard handheld trephine without a
guard may be used, taking great care to avoid causing
protrusion of ocular contents through the perforation site.
Some surgeons prefer to mark the supercial cornea with
the trephine and deepen the mark freehand with a blade.
The cornea is entered through the deepened trephination
mark. If the perforation is not due to infection, curved
corneal scissors can be introduced through the perforation
and a freehand excision of the recipient cornea can be
performed. In any case, extreme care must be taken to
avoid cutting iris or lens. One alternative method involves
the use of a suction trephine system such as the Hessburg-
Barron trephine. In this way pressure is exerted outward
by the suction apparatus, avoiding direct pressure on the
open globe. Once the trephine is secured on the cornea by
suction, trephination is accomplished by simply rotating
the blade of the trephine. Another alternative procedure
involves using nonmechanical excimer laser trephination.
55
In this method, the anterior chamber is re-formed using
viscoelastic material. Stainless steel metal aperture masks
are used to cover and protect the central cornea of the
donor and the peripheral cornea of the recipient during
excimer trephination.
Others have advocated the temporary use of tissue
adhesive with or without scleral or corneal patches to
restore the anterior chamber minutes before trephination.
56
In this way traditional trephination can then be accom-
plished in a safer, more effective manner. In our opinion,
most lesions amenable to such patches and adhesive
would benet from re-formation and observation followed
by keratoplasty days to weeks later rather than on an
emergent basis. In addition, perforations large and severe
enough to require keratoplasty are unlikely to re-form
temporarily with adhesive and/or patch; however, this
technique is occasionally useful.
The recipient cornea is removed with curved corneal
scissors. This step can be more difcult than usual because
corneal opacication may hinder the surgeons view. Care
must be taken to avoid cutting uvea, lens, or intraocular
lens, which may be displaced anteriorly. If vitreous is
adherent to the cornea, it should be cut with Wescott or
deWecker scissors before removal of the button. Once the
recipient button is removed, the anterior chamber should
be inspected for peripheral anterior synechiae, posterior
synechiae, and cataract. In most situations, cataract
removal is left for a subsequent procedure because the risk
of expulsive hemorrhage, vitreous loss, endophthalmitis,
and sequestered organisms may be higher at the time of
the initial procedure. Posterior and anterior synechiae
should be gently lysed and one or multiple peripheral
iridectomies performed. The anterior chamber is then
patient is not admitted, outpatient antibiotic treatment
with an oral fluoroquinolone (e.g., ciprofloxacin, 500mg
twice a day, levofloxacin 500mg once a day, or moxifloxacin
400mg once a day) seems most reasonable because of the
fluoroquinolones excellent ocular penetration. It is also
important to check the status of the fellow eye carefully
and to add lubrication in this eye, if clinically indicated.
Infected corneal perforations are always admitted and,
if a bacterial infection is suspected, the patient is started
on fortied topical antibiotics (e.g., cefazolin, 50mg/ml,
or vancomycin, 25mg/ml, plus tobramycin, 15mg/ml or
a topical fluoroquinolone (gatifloxacin, moxifloxacin or
ciprofloxacin)), every hour around the clock. These medi-
cations can be tapered appropriately over the next several
days, depending on the clinical response and culture and
sensitivity results. Antiviral or antifungal therapy should
be instituted if a herpetic or fungal etiology is suspected.
One must carefully balance the need for frequent topical
medications against the desire to manipulate the eye as
little as possible. Prophylactic intravenous antibiotics may
also be administered. The position of the glue and contact
lens are evaluated daily until discharge and then again in
3 to 5 days. If the glue and contact lens remain in place,
the patient may be discharged once the infection is
resolving. Patients must be made aware that if they notice
a sudden change in vision, pain, discharge, photophobia,
tearing, or appearance of the eye, immediate follow-up
examination is necessary.
If the glue becomes dislodged, the situation must be
reevaluated. If the remaining defect can be reglued, this
procedure should be attempted as needed. In some situ-
ations, several reapplications may be necessary before a
stable adhesion is obtained. Any contact lens that has
become dislodged should be replaced as soon as possible.
If the glue repeatedly dislodges or if the resultant per-
foration is too large to repair with tissue adhesive, other
modalities (e.g., penetrating keratoplasty or patch graft)
must be considered.
Ideally, the glue should remain in place for weeks to
months while stromal healing and vascularization occur
beneath it to stabilize the cornea. The contact lens should
remain in place for as long as the glue is present to
maximize patient comfort. We typically replace the bandage
contact lens every 2 to 3 months, or more frequently if
necessary. Contact lens replacement must be performed
with extreme care so as not to dislodge the glue. We use an
eyelid speculum to prevent accidental eyelid closure and
disturbance of the glue. Prophylactic topical antibiotics
(e.g., trimethoprim/polymyxin B, levofloxacin, gatifloxacin
or moxifloxacin) should be continued during contact lens
use. The appropriate time for removal of the glue is contro-
versial. As a rule, we tend to leave the glue in place until
it loosens excessively or becomes totally dislodged. If
the stroma appears healed, the glue can theoretically be
removed after several months. However, the risk of per-
foration still exists. Tissue adhesive has remained on the
eye for up to 660 days before spontaneously sloughing,
with subsequent perforation 30 days later from recurrent
stromal thinning.
36
Management after glue has been removed and stromal
healing has occurred is also variable. Peripheral lesions
not affecting the visual axis or other lesions in eyes with
limited visual potential can be managed conservatively.
Years after the gluing, one may see only a faint stromal
scar, with little other evidence of previous perforation. In
other cases, dense brosis, with or without uvea incorporated
into the scar, and vascularization may persist. If visual
rehabilitation is desired, elective penetrating keratoplasty
and/or anterior segment reconstruction can be attempted
6 to 12 months later.
Complications
Although tissue adhesives are well tolerated by the eye,
several complications have been reported. These include
cataract formation
11,50
(thought to be due to direct contact
of glue with the lens), corneal inltration
3,36
(infectious
and noninfectious), glaucoma,
3
giant papillary conjunc-
tivitis,
51
retinal toxicity,
52
granulomatous keratitis,
53
and
symblepharon formation.
36
It is often difcult, however, to
determine whether the complication was due to the use of
tissue adhesive or the original perforation.
Penetrating keratoplasty
Larger perforations not amenable to repair using tissue
adhesive or tissue adhesive failures are often treated with
penetrating keratoplasty (Fig. 137.7). The timing of surgery
is quite variable. If tissue adhesive has been applied and the
integrity of the eye restored, keratoplasty can be deferred
for days to months, depending on the stability of the
clinical situation.
Patients with acute perforations that require surgical
repair by keratoplasty should be admitted to the hospital,
given intravenous antibiotics (e.g., cefazolin or vancomycin
plus gentamicin, tobramycin or ceftazidime), and not per-
mitted to receive food or drink by mouth until the repair
can be performed. If an infection is suspected, the appro-
priate topical and systemic antibiotics, antivirals, or anti-
fungals should be administered. Some advocate medical
therapy for at least 24 hours before attempting any surgical
intervention.
4
In some situations, gentle B-scan ultra-
sonography can be invaluable in detecting the presence of
hemorrhagic choroidal detachments. If detachments are
present, one should obtain the advice of a vitreoretinal
surgeon and seriously consider waiting several days before
attempting keratoplasty and/or drainage of the choroidal
hemorrhage because of the increased risk for expulsive
hemorrhage.
The use of general anesthesia, with the anesthesiologist
well aware that the globe is open, is usually preferred. A
Barraquer eyelid speculum is then inserted, making sure
that no external pressure is placed on the globe. In situ-
ations in which the anterior chamber is flat or the eye is
soft, attaching a Flieringa ring is quite difcult, and this
step may be omitted. The recipient trephine size is gener-
ally determined by the size and location of the existing
perforation. The smallest trephine capable of incorporating
the perforation site and any infected or ulcerated border
is generally chosen. Trephine sizes usually vary between
Management of Corneal Perforations
CHAPTER 137
Section 1: Corneal Surgery
PART X: THERAPEUTIC AND RECONSTRUCTIVE PROCEDURES
Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages Sample Pages
Fig. 137.7 Penetrating keratoplasty. A, Large perforated corneal
ulcer in a patient with chronic HSV keratitis. B, Slit lamp view
demonstrating the large size of the full-thickness perforation. C, This
patient was treated with an emergent penetrating keratoplasty.
A
B
C

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Patients with acute perforations that require surgical Patients with acute perforations that require surgical Patients with acute perforations that require surgical
repair by keratoplasty should be admitted to the hospital, repair by keratoplasty should be admitted to the hospital, repair by keratoplasty should be admitted to the hospital,
given intravenous antibiotics (e.g., cefazolin or vancomycin given intravenous antibiotics (e.g., cefazolin or vancomycin given intravenous antibiotics (e.g., cefazolin or vancomycin
plus gentamicin, tobramycin or ceftazidime), and not per- plus gentamicin, tobramycin or ceftazidime), and not per- plus gentamicin, tobramycin or ceftazidime), and not per-
mitted to receive food or drink by mouth until the repair mitted to receive food or drink by mouth until the repair mitted to receive food or drink by mouth until the repair
can be performed. If an infection is suspected, the appro- can be performed. If an infection is suspected, the appro- can be performed. If an infection is suspected, the appro-
priate topical and systemic antibiotics, antivirals, or anti- priate topical and systemic antibiotics, antivirals, or anti- priate topical and systemic antibiotics, antivirals, or anti-
fungals should be administered. Some advocate medical fungals should be administered. Some advocate medical fungals should be administered. Some advocate medical
therapy for at least 24 hours before attempting any surgical therapy for at least 24 hours before attempting any surgical therapy for at least 24 hours before attempting any surgical
In some situations, gentle B-scan ultra- In some situations, gentle B-scan ultra- In some situations, gentle B-scan ultra-
sonography can be invaluable in detecting the presence of sonography can be invaluable in detecting the presence of sonography can be invaluable in detecting the presence of
O
F

is quite variable. If tissue adhesive has been applied and the is quite variable. If tissue adhesive has been applied and the is quite variable. If tissue adhesive has been applied and the
integrity of the eye restored, keratoplasty can be deferred integrity of the eye restored, keratoplasty can be deferred integrity of the eye restored, keratoplasty can be deferred
for days to months, depending on the stability of the for days to months, depending on the stability of the for days to months, depending on the stability of the
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mitted to receive food or drink by mouth until the repair mitted to receive food or drink by mouth until the repair mitted to receive food or drink by mouth until the repair
can be performed. If an infection is suspected, the appro- can be performed. If an infection is suspected, the appro- can be performed. If an infection is suspected, the appro-
priate topical and systemic antibiotics, antivirals, or anti- priate topical and systemic antibiotics, antivirals, or anti- priate topical and systemic antibiotics, antivirals, or anti-
fungals should be administered. Some advocate medical fungals should be administered. Some advocate medical fungals should be administered. Some advocate medical
therapy for at least 24 hours before attempting any surgical therapy for at least 24 hours before attempting any surgical therapy for at least 24 hours before attempting any surgical
In some situations, gentle B-scan ultra- In some situations, gentle B-scan ultra- In some situations, gentle B-scan ultra-
sonography can be invaluable in detecting the presence of sonography can be invaluable in detecting the presence of sonography can be invaluable in detecting the presence of
hemorrhagic choroidal detachments. If detachments are hemorrhagic choroidal detachments. If detachments are hemorrhagic choroidal detachments. If detachments are
present, one should obtain the advice of a vitreoretinal present, one should obtain the advice of a vitreoretinal present, one should obtain the advice of a vitreoretinal
surgeon and seriously consider waiting several days before surgeon and seriously consider waiting several days before surgeon and seriously consider waiting several days before
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repair by keratoplasty should be admitted to the hospital, repair by keratoplasty should be admitted to the hospital, repair by keratoplasty should be admitted to the hospital,
given intravenous antibiotics (e.g., cefazolin or vancomycin given intravenous antibiotics (e.g., cefazolin or vancomycin given intravenous antibiotics (e.g., cefazolin or vancomycin
plus gentamicin, tobramycin or ceftazidime), and not per- plus gentamicin, tobramycin or ceftazidime), and not per- plus gentamicin, tobramycin or ceftazidime), and not per-
mitted to receive food or drink by mouth until the repair mitted to receive food or drink by mouth until the repair mitted to receive food or drink by mouth until the repair
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