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

Visual Rehabilitation

Histopathologic examination of corneas with previous injuries reveals acute, subacute, or chronic inflammatory changes and fibrous membranes in well-closed corneal wounds. Fistulae were observed in inadequate wound closure caused by epithelial ingrowth, iris and vitreous embedment, and deficiency of corneal tissue.[47] Corneal trauma can rarely result in keloid formation. A case has been described of a patient who experienced corneal trauma from a fingernail and then developed a slowly progressive whitish elevated lesion. On histopathology, the lesion was made of randomly oriented collagen fibers, fibroblasts, and myofibroblasts, similar to skin keloids.[48]

Corneal sutures and subsequent scarring from previous wounds frequently produce high astigmatism.[3,49–51] Computerized videokeratography shows significant reduction in topographic distortion after removal of these sutures. There is no correlation between laceration configuration with final topography, but those near central axis are more likely to have >2.00 D of final astigmatism.[49,50]

Unexpected refractive sequelae can occur from previous corneal trauma. A myopic patient with refractive error of -3.50–1.50×170 experienced a bungee cord injury resulting in a radial partial thickness corneal laceration, which was treated with topical antibiotics. Posttraumatic visual acuity improved to 20/20 without corrective lens secondary to central flattening from the radial keratotomy-like injury.[51]

Contact Lenses

A more conservative approach to visual rehabilitation involves using rigid gas-permeable (RGP) contact lenses to mask the irregular astigmatism created by the healed wound. A study of 33 posttraumatic scarred cornea of 33 patients indicated that RGP contact lenses were successful in the majority of patients (82%) and may preclude corneal surgery.[52] Improved visual outcome occurs more in patients with smaller, peripheral lesions and in younger patients.[53,54] For patients who have become intolerant to RGP contact lenses, the PROSE (Prosthetic Replacement of the Ocular Surface Ecosystem) lens has been shown to significantly improve visual acuity and visual function in patients with irregular astigmatism who have failed conventional therapy.[55] Another option for visual rehabilitation after corneal wound repair is laser refractive surgery. LASIK has been used in rare cases for visual rehabilitation after corneal laceration repair.[56]

Corneal Grafting

Achieving visual axis clarity is the goal of corneal grafting after a cornea has been scarred by previous trauma. Conventional penetrating keratoplasty should be delayed for at least 3 months after primary repair to significantly improve the chances of graft success.[57] Femtosecond laser-assisted keratoplasty for posttraumatic corneal scarring has also been reported with promising results.[58]

IOL Implantation

After corneal laceration repair, IOL implantation can cause unexpected refractive outcomes if relying on measurements from the contralateral eye. One should use measurements of the injured eye after the corneal wound has healed, to allow for most accurate keratometric measurements.[59] IOL implantation at the time of lensectomy and primary repair of corneal laceration has also been described successfully, with good visual rehabilitation and outcomes.[60,61]

Pediatric Visual Rehabilitation

Pediatric cases present complex management issues because these patients are at risk for amblyopia. Prevention of intractable amblyopia is best achieved by restoring clear media, correcting refractive error, and ensuring use of the injured eye. To prevent amblyopia, authors report using spectacle or contact lens correction and initiating occlusion therapy as soon as possible after repair of the injury. Patching treatment is recommended almost immediately after surgical repair.[62] Other case series report successful surgical rehabilitation and near emmetropia in pediatric patients with corneal lacerations by combining surgery (IOL implantation and corneal transplantation) with aggressive amblyopia therapy.[63,64]

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