Some perforating injuries are so minimal that they seal spontaneously before ophthalmic examination, with no intraocular damage, prolapse, or adherence. These cases may require only systemic and/or topical antibiotic therapy along with close observation. Small, nongaping wounds may be treated as corneal abrasions with patching or a bandage contact lens until the epithelial defect has resolved and the patient is comfortable.
If a corneal wound is leaking (ie, the Seidel test result is positive; see Chapter 2, Fig 2-22) but the anterior chamber remains formed, the clinician can attempt to stop the leak with the following interventions, used in combination or alone: pharmacologic suppression of aqueous production (topical [eg, β-blocker] or systemic), patching, a therapeutic contact lens, or a tissue adhesive. Generally, if these measures fail to seal the wound within 2 days, surgical closure with sutures is recommended. If the corneal wound is leaking in the presence of a very shallow or flat anterior chamber, urgent surgical repair is required.
When a foreign body is present, the management of a corneal perforation poses a special challenge. The Descemet membrane is the strongest structural barrier to perforation of the cornea; foreign bodies may penetrate through the stroma and lodge anterior to the Descemet membrane. It may be difficult to determine whether removal of a deep foreign body will dislodge a self-sealed wound, so judicious decision making is mandatory. If multiple, very small foreign bodies are seen in the deep stroma (as may occur after an explosion) with no resultant inflammation or sign of infection, the patient may be monitored closely, given that aggressive surgical manipulation of the cornea in search of the very last particle may be unnecessary. If anterior chamber extension is present or suspected, the foreign body should be removed in a sterile environment such as an operating room. Overly aggressive attempts to remove deeply embedded foreign bodies at the slit lamp may result in leakage of aqueous humor and collapse of the anterior chamber.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.