Management of Corneal Lacerations and Perforations

Gargi K. Vora, MD; Ramez Haddadin, MD; James Chodosh, MD, MPH

Disclosures

Int Ophthalmol Clin. 2013;53(4):1-10. 

In This Article

Mechanisms of Injury

Classic Injuries

Corneal lacerations are classically associated with high-speed projectiles or sharp objects, but blunt contusions can also result in corneal rupture.[3] A study of 36 children with corneal lacerations reported the trauma occurred mainly by missiles with stones and catapults.[5] In another study, the most frequent cause of perforating eye injury was caused by glass or knives.[7]

Sports-related injuries are common mechanisms for corneal lacerations. The United States Eye Injury Registry, which has a total of 9293 reported cases of eye trauma, reports baseball injuries first in sports-related eye injury, with fishing-related injuries as second. Of the 143 fishing-related injuries, 45 (27.6%) patients presented with corneal laceration or rupture.[8]

Iatrogenic Injuries

Iatrogenic corneal injuries have been reported mostly in the earlier refractive surgery literature, often during the laser ablation part of the laser-assisted in situ keratomileusis (LASIK) procedure.[9–13] Corneal perforation can occur because of excessive stromal bed dehydration from prolonged exposure to the operating microscope.[9] Unpredictable corneal thinning from prior procedures such as previous electrothermokeratoplasty scars has also caused perforations during LASIK ablation.[13] Rarely, machine malfunction can also cause repeated ablation at a single location, thereby causing a corneal perforation.[11] Recurrent and progressive epithelial downgrowth can complicate these perforations and be difficult to manage and thus, care should be taken to avoid manipulating or lifting the flap during repair.[10,11,14] Although no longer a common procedure, conductive keratoplasty for treatment of refractive error has also reported to cause corneal perforations during insertion of the keratoplasty tip.[15,16]

Noncorneal laser procedures have also resulted in corneal perforations, usually due to misdirection of the laser by media opacity.[17,18] A patient who had a previous history of corneoscleral laceration repair and resultant leukoma underwent Nd:YAG laser capsulotomy after secondary intraocular lens (IOL) placement for a visually significant posterior capsular opacification. Focusing error from the cornea opacity may have caused a resulting shock wave, which perforated an area of thinned cornea.[17] Argon laser photocoagulation of the retina has also been reported to cause a corneal perforation. The authors hypothesized that pigmented material between the cornea and lens interface may have misdirected the laser beam, thus causing this rare complication.[18] Finally, carbon dioxide laser blepharoplasty has been reported to cause bilateral corneal perforations.[19]

Another iatrogenic cause of corneal perforation is from eyelid injection of anesthetic for oculoplastics procedures.[20,21] In one case, the patient developed endothelial toxicity and secondary angle closure glaucoma from the intraocular anesthetic mixture.[21]

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