Corneal Perforation Management: A Practical Surgical Decision Guide

Selecting the appropriate intervention for corneal perforation remains challenging in daily practice. Variability in management often leads to repeated procedures, delayed tectonic stabilization, or unnecessary emergency keratoplasty. We present a practical clinical decision framework linking perforation characteristics to the most suitable surgical approach.

Tertiary referral ophthalmology center, cornea and anterior segment service.

A structured management algorithm was developed from real-world surgical experience supported by current literature. Decision nodes incorporated perforation size, location, disease activity, and ocular surface status. Representative cases were used to evaluate applicability and demonstrate outcomes following each escalation step, from tissue adhesive to keratoplasty.

Small perforations (≤2–3 mm) were stabilized with cyanoacrylate adhesive when the underlying disease was controlled. However, adhesive failure was common in active inflammatory melts and neurotrophic disease. Moderate defects (2–4 mm) required structural support with amniotic membrane transplantation or patch grafting. Peripheral ectatic perforations responded well to patch grafting, while inflammatory etiologies required earlier surgery. Larger perforations (>3–5 mm), or those with progressive melt, required lamellar or penetrating keratoplasty for definitive reconstruction. Early escalation reduced repeat procedures and improved structural outcomes, whereas delayed surgery increased urgent keratoplasty and postoperative complications.

Corneal perforation management is primarily a decision-making problem rather than a technical one. A structured size- and etiology-based framework helps surgeons select the appropriate timing and type of intervention. Applying this approach can minimize unnecessary procedures, reduce emergency keratoplasty, and improve tectonic stability in routine clinical practice.