Surgical therapies for corneal perforations: 10 years of cases in a tertiary referral hospital

Abstract

Purpose: To report surgical therapies for corneal perforations in a tertiary referral hospital.

Methods: Thirty-one eyes of 31 patients (aged 62.4±18.3 years) with surgically treated corneal perforations from January 2002 to July 2013 were included in this study. Demographic data such as cause of corneal perforation, surgical procedures, and visual outcomes were retrospectively analyzed.

Results: The causes of corneal perforation (n=31) were divided into infectious (n=8, 26%) and noninfectious (n=23, 74%) categories. Infectious causes included fungal ulcer, herpetic stromal necrotizing keratitis, and bacterial ulcer. The causes of noninfectious keratopathy included corneal melting after removal of a metal foreign body, severe dry eye, lagophthalmos, canaliculitis, the oral anticancer drug S-1, keratoconus, rheumatoid arthritis, neurotrophic ulcer, atopic keratoconjunctivitis, and unknown causes. Initial surgical procedures included central large corneal graft (n=17), small corneal graft (n=7), and amniotic membrane transplantation (n=7). In two cases the perforation could not be sealed during the first surgical treatment and required subsequent procedures. All infectious keratitis required central large penetrating keratoplasty to obtain anatomical cure. In contrast, several surgical options were used for the treatment of noninfectious keratitis. After surgical treatment, anatomical cure was obtained in all cases. Mean postoperative best corrected visual acuity was better at 6 months (logMAR 1.3) than preoperatively (logMAR 1.8).

Conclusion: Surgical therapies for corneal perforations in our hospital included central large lamellar/penetrating keratoplasty, small peripheral patch graft, and amniotic membrane transplantation. All treatments were effective. Corneal perforation due to the oral anticancer drug S-1 is newly reported.

Keywords: amniotic membrane transplantation; corneal perforation; keratoplasty.

Figure 1

Representative slit-lamp biomicroscopic photograph of a noninfectious corneal perforation treated by a central penetrating large graft. Notes: (A) A 74-year-old man with a paracentral corneal perforation due to the anticancer drug S-1 (TS-1 capsule, 100 mg/day, Taiho Pharma, Tokyo, Japan). The iris prolapse in the lower paracentral cornea and the shallow anterior chamber with bandage soft contact lens (stained by fluorescein) are shown. (B) Two weeks after penetrating keratoplasty, the anterior chamber was re-formed.

Figure 2

Representative slit-lamp biomicroscopic photograph of a noninfectious corneal perforation treated by a central lamellar large graft. Notes: (A) A 47-year-old woman with a corneal perforation associated with a neurotrophic ulcer due to trigeminal nerve palsy with brain tumor. A large paracentral corneal perforation and shallow anterior chamber are shown. (B) Three months after anterior lamellar keratoplasty, the anterior chamber was re-formed.

Figure 3

Representative slit-lamp biomicroscopic photograph of a noninfectious corneal perforation treated by a small patch graft. Notes: (A) An 83-year-old man with a corneal perforation associated with canaliculitis. The iris prolapse (arrow), the shallow anterior chamber, and swelling on the superior canaliculus (arrowheads) are shown. Anaerobic bacteria (Peptostreptococcus, Prevotella, and Porphyromonas spp.) were detected by culture of the concretions in the canaliculus. (B) One year after a peripheral anterior lamellar patch graft with removal of the concretions in the canaliculus. The postoperative best corrected visual acuity was 20/200.

Figure 4

Representative slit-lamp biomicroscopic photograph of a noninfectious corneal perforation treated by amniotic membrane transplantation. Notes: (A) A 70-year-old man with a corneal perforation associated with severe dry eye of mucous membrane pemphigoid. A paracentral small perforation was noted in the corneal ulcer with a positive Seidel test. Inflamed conjunctiva, corneal pannus, and symblepharon were noted. (B) One year after treatment with cryopreserved human amniotic membrane with punctal occlusion. The ocular surface was re-epithelialized and the best corrected visual acuity was equal to the preoperative level (counting fingers).

Figure 5

Visual outcomes of 25 cases that were followed for longer than 6 months after corneal perforation repair. Abbreviations: CF, counting fingers; HM, hand motions; LP, light perception.