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    Manejo de Perforaciones Corneales

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    Como debes manejar las perforaciones oculares

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    9 Chapter 137 NS Management of Corneal Perforations Marc A. Honig — Christopher J. Rapuano verforations can result from a variety of disorders jn can lead to devastating visual sequelae. Descemetoceles ing perforations are ophthalmic emergencies that require Ei recognition and intervention. The primary Je infection, inflammation, and trauma, How- conditions such as exposure and neurotrophic xerosis, and corneal degenerations can also se ulceration and perforation (Box 137.1). Conditions fa descemetocele and perforation are briefly out- ine The work-up and treatment of these disorders ure cliscussed at length elsewhere in this edition. y nent should be directed toward prevention of ‘ ‘oration, because once a perforation has occurred, sutcome is often disappointing. Recognition of hi ions leading to perforation and management f vrated comea are discussed. Treatment of traumatic are not discussed in depth here because this jored in great detail in other chapters. Etiology r common cause of comeal perforation is infec- ' bacteria, fungal, or viral. Infection accounts for be 4% and 55% of all perforations," with bacterial I __ | 137.1 cote a |e os (bacterial, fungal, veal [herpes simplex, herpes zoster) cae aes pence tuSSeneds grantomatesi, Moore’ idlopatil wee) |. ne Fee ee artcia pempnigod, vitamin A deficiency) oo a eas ‘on, floppy eyelid syndrome) toe Cr Js (tract entation, LASIK PRK, ete pang Pe hc gumocenon mmm, sacors meant infections being most common A frequent predisposing factor leading to these and other types of perforations is early breakdown of the corneal epithelium. Once this barrier is compromised, the pathogen gains easy access to the stoma, inciting an inflammatory response in the host Damage results from a combination of direct microbial invasion, and more importantly, through host chemotaxis, of leukocytes, causing collagenases to be released and corneal ulceration to occur. Viral keratitis, namely herpes simplex (HSV) and herpes zoster (HZV), may lead to corneal perforation secondary to recurrent active ulcerative keratitis, persistent epithelial defects, and neurotrophic keratopathy.” Fungal infections are less common and often progress more slowly than other forms of infectious ulcerative keratitis, but nonetheless may lead to corneal perforation. Inflammatory conditions such as collagen vascular diseases, acne rosacea, Wegener's granulomatosis, and ‘Mooren’s (idiopathic) ulcer can also cause peripheral, and ‘occasionally central, ulcerative keratitis and subsequent perforation. The use of topical corticosteroids and topical nonsteroidal anti-inflammatory drugs (NSAIDs), may ‘exacerbate or initiate a stromal melt in the presence of one of these disorders, but perforation can also occur spontaneously.!"!? Trauma, either chemical, thermal, surgical, or penetrating, is also a common cause of corneal perforation. Chemical injuries, alkali burns in particular, may cause devastating corneal damage, initially by direct tissue destruction and later by induction of stromal melting and necrosis because of the elaboration of collagenases."® Thermal injury normally causes superficial comeal damage but may, in rare instances, cause perforation because of extreme heat or associated ‘mechanical injury. Corneal ulceration and perforation. have also been reported after cataract extraction, both with and without intraocular lens implantation, '*"* LASIK,! PTK,"® pterygium excision with use of mitomycin-C,"? and rarely after argon laser photocoagulation Xerosis and exposure keratopathy are also causes of corneal perforation.” Xerosis may be idiopathic; related to collagen vascular disease (Sjogren's syndrome); or second ary to Stevens-Johnson syndrome, ocular cicatricial pemphigoid, or vitamin A deficiency. Exposure may result from seventh nerve palsy, thyroid ophthalmopathy involutional ectropion, floppy eyelid syndrome, or chronic cicatrizing eyelid disorders. Sa UTllt—“‘i—=™ " PART X: THERAPEUTIC AND RECONSTRUCTIVE PROCEDURES. Section 1: Comeal Surgery Corral ce fon EL 2 coreg Neurotrophic keratopathy is most common fection, typically HSV and HZ trating keratoplasty, cataract extraction, LASIK). The lack of corneal sensation leads to chronic epithelial break- down with slow healing. This persisten makes the cornea susceptible to a sterile melting process infectious Keratitis and potential perforation. Corneal degenerations such as Terrien’s margi degeneration can lead to slow, progressive thinning, which may rarely proceed to perforation, Corneal ectatic dis. orders such as keratoconus, keratoglobus, or pellucid mar ginal degeneration may present with extreme thinning and ectasia, Perforation in these situations is exceedingly rare, but can occur as a resu trauma, especially n Keratoglobus,” and has also been reported in. pellucid marginal degeneration."** Corneal rupture and fistulization after acute hydrops in keratoconus are also uncommon bu! have been described, Terminology refers to a defect in the epithelial layer with some degree of stromal loss, often with infiltration or necrosis (Fig. 137.1) Descemetocele refers to a lesion in which there is destruc: impending perforation is less specific, but typically re" tion of the epithelium and stroma, with only Descemet’s any ulceration with severe stromal thinning that clini membrane and endothelium remaining (Fig. 137.2). appears capable of perforating in the near future. Peroni Because of its highly elastic nature and the intraocular refers to a situation in which there is a definite pressure, Descemet’s membrane often bulges anteriorly, thickness defect in the cornea and there is communication forming the classic dome-shaped, transparent membrane, between the anterior chamber and surface of the &© which is easily recognized at the slit lamp (Fig. 137.3). At descemetocele through which aqueous is percolating 8 this stage, the comea is in imminent danger of perforation. technically a true perforation, but is often refered (0% A comea that has thinned to the level of Descemet’s leaking descemetocele. Regardless of terminology, an 5 membrane but contains an epithelialized surface is best. epithelialized, severe thinning of the cornea must Be 4701 described as a healed descemetocele and is at much less treated as a therapeutic emergency that requifes Prom risk for further ulceration and perforation. The term intervention. hat eee Sign Desc wea of ris prolapse covered with smooth, cemet’s membrane this eye with chronic nd Symptoms of netocele and Perforation of patients with a leaking tion experience an abrupt decrease in visual descemetocele or sociated pain; however, the clinical presen ite variable. Ulceration and perforation in wealthy eye may cause the patient to notice set of symptoms sooner than in a sick or which may already have poor visual acuity ort. Similarly, a neurotrophic eye may not nange in symptoms, other than possibly a val acuity nptoms may be attributa jeeper pain secondary to Iris or cl je choroidal detachments from rapid decom: he eye. Acute perforations may also cause cof aqueous, which the patient may simply ss tear production. Patients at high risk for hhould be made aware of the possible symp- ld to seek immediate ophthalmic attention if iccur. In eyes with extremely thinned comeas, lastic shield or glasses during the day and itime should he recommended, thalmologist examining a patient with a sus- metocele or perforation must treat the situation nat of an open globe from other causes. The be discouraged from squeezing during the and minimal manipulation of the globe and le to ocular surface splication of topical medications should be A careful medical and ophthalmic history tained to help determine the etiology of the nterior chamber, positive Seidel test, anc uvea signs of corneal perforation are flat CHAPTER 137 Management of Corneal Perforations prolapse. For the Seidel test, we prefer the use of a sterile Finorescein strip saturated with a small amount of sterile saline to paint the suspected area of perforation. The presence of clearing or dilution of fluorescein dye under Slit lamp examination with the cobalt blue filter is evi- ence of a definite perforation. Examination may reveal an ‘obvious perforation with the above signs; however, in many situations, signs of pesforation may be more subtle. Uveal prolapse may plug a wound causing re-formation of the anterior chamber and a negative Seidel test. Applying gentle pressure from above or below often may yield a positive Seidel sign, which is not present without any external manipulation, If the anterior chamber Is completely flat, the Seidel test Is often negative, even in the presence of a frank perforation, These characteristics are summarized in Box 137.2, Infectious ulcers with a significant amount of purulent material and mucus can be difficult to evaluate for a perforation. If a central clear zone exists within a large, dense infiltrate, a perforation or descemetocele should be suspected. Any shallowing of the anterlor chamber on sequential examinations in the absence of high intraocular pressure and pupillary block is presumptive evidence of perforation. The presence of a hypopyon that suddenly Clears on subsequent reexamination should also raise one’s, suspicion that a perforation has occurred. In an impending perforation, the only sign may be radiating folds in Descemet’s membrane emanating from the base of the ulcer.” This sign may be particularly helpful in cases in which the infiltrate and necrotic stroma ebscure the view An intact epithelium does not imply that a corneal per foration has not occurred. Chronic perforations with uve: or other material plugging the wound can reepithelialize neously. These cases often require intervention: however, because the epithelium provides a moderately effective barrier to infection, repait can be performed on int rather than emergent basis. After a suspected perforation is confirmed at the bedside or slit lamp, atten- tion should then be directed to repair and restoration of the integrity of the globe as soon as possible Box 137.2 Signs and symptoms of perforation and descemetocele | Shalow or fat anterior camber (peoration) Fesive Sil et perforation | ved sue tothe posterior comea or fank prolapse (peroraton) oa entrar zone often bulging) within area of inflate or thinning (escemetocee. ating fle n Desceret's membrane emanating fiom the tse Of the ueerationescometocele) = 1671 | 1672 “Section 1: Comeal Surgery — Preoperative Management Aiter a perforation Is detected, the ophthalmologist must then determine whether comection ef the problem can be accomplished as an inpatient or outpatient, whether ican ire performed at the bedside o sit amp, or whether surgical imtervention in the operating room is warranted TE surgical repair is definitely indicated, the patient should not receive food or drink by mouth, and a deter mination should be made of the last time food or drink tas ingested. Inthe presence of infection, systemic intra enous antibiotics (eg, cefazolin, intravenously every S hours, and gentamicin, 6 mg/kg ideal body weight intra venously every 24 hours, assuming normal creatinine lea. ance, or ceftazidime, 1g intravenously every 8 hours) are Administered beginning as soon as posible and continued for atleast 24-72 hours Iti also generally agreed that all perforated ulcers and_descemetoceles thought to. be Infectious in origin should be gently scraped or swabbed and sent for Gram and Giemsa stains, as well a cultures nd sensitivities Ifthe perforation is thought to be sterile or the patient cannot be admitted to the hospital, oral Ciprofloxacin (500 mg by mouth, twice a day, levofloxacin (S00 mg by mouth, once a day) or moxifloxacin (400 mg by mouth, once a day) may be used prophylactically as a second choice to intravenous antibiotic. A plastic shield should be placed over the eye; and manipulation on the part of the patient, ophthalmologist, and nursing staff should be kept to a minimum. In general ifthe anterior chamber is flat, repair (regardless of method) should be performed within the fst 24 to 48 hours to avoid per manent peripheral anterior synechiae and damage to the Treatment options issue adhesives Cyanoacrylate glue Cyanoacrylate glue has been used since the late 1960s when Webster et al" reported the repair of two perforated ulcers with n-heptyl-2-cyanoacrylate. Since then, corneal aluing has become an increasingly popular treatment modality because of its high efficacy, relative ease of appli ‘ation, and its ability to delay an otherwise emergent surgical repair in the operating room. Hirst et a" reported a trend toward a lower enucleation rate and better visual results in perforations treated with corneal glue, When effective, the application of corneal glue can immediately restore structural integrity to the globe. In these situations, penetrating keratoplasty or other more permanent pro. ‘edures can be avoided or at least delayed until a time when the eye is quiet, and surgical intervention has a better chance of success, Nobe et al" reported that, for both infectious and traumatic perforations, corneal transplantation had a better, chance of remaining clear if keratoplasty could be delayed. ‘Complicating factors relating to penetrating keratoplasty in the acute setting of perforation include synechia for mation, glaucoma, uveitis, and eventual graft rejection and failure in these inflamed eyes." The success TA cpl antl ie ge 6 a Kenyon’ and others have Gu the importance of eae thinning disorder before perforation ce I the procedure much easier to perform on a nonperony process of ulceration. In addition, Fiferman and Says alone.*** Penetrating or lamellar keratoplasty, however, required enucleation or evisceration.** The resulting ations because they provide a concave surface as opposed have found tissue adhesives more useful in peripheral attempting corneal gluing before undertaking an emergent surgical procedure. In peripheral ulcers, the glue is mote Primarily because the glue also covers an adjacent areaot with both central and peripheral perforations, the BUE Despite lack of approval by the Food and Dalé Administration (FDA), Histoacryl blau D-3508 (Melsunge” commonly used tissue adhesive for the comea..”2" Ie is been available in Canada, but not in the United State however, it is difficult to obtain at the present time Another polymer, n-buty! cyanoacrylate (Nexacayl ical L.P,, Raleigh, NC) had been used experi several centers wi .en FDA approved ophthalmic use.%* Recent cess has been reported using another polymer, acrylate.” This adhesive, with the trade (Ethicon Inc., Summerville, NJ), is available and is FDA approved as a skin conveniently packaged in individual ampules longer available. Anecdotally, others have lental glue, Isodent (Ellman Inc —— _ Management of Corneal Perforations tages of cyanoacrylate glue and is degraded physiologically and Human Fibrin Glue" (HFC Baxter, Deerfield, IL, USA or Tissucol, Baxter, Belgium) have on with amnioti cyanoacrylate Tisseel, been used in conjunc (AMT later in this chapt Method of application Many techniques for application of tissue adhesives have been described, all of which rely on the same basic principles but vary in the instruments or applicators used to apply the adhesive in a delicate, controlled fashion. The common jue possible to minimize excess glue protruding from the surface or on the adjacent normal cornea. We describe in detail one method and later list modifications that also xist (Fig. 137.4). Box 137.3 lists the equipment necessary Boe eee aren Equipment needed for application of tissue adhesive ‘it lamp or operating micrascope Barraquer eyelid speculum Tissue adhesive Cellulose spears Sterile drape (i available) Bandage soft contact lens Preservativecree artificial tears Cotton-tipped applicators ‘Ophthalmic ointment Topical anesthetic drops Balanced salt solution Jeweler’ forceps Viscoelastic substance Careful slit lamp examination and drawings should be performed before the application of any tissue adhesive, because after gluing and placement of a bandage soft contact lens, subsequent examination of the perforation site may be difficult. Particular attention should be focused. on the size and extent of the perforation, Chrus of the lens and the presence of uveal py Balsne the application of the glue, we prefer to Sperating microscope in the office or minor surge cath the patient in the supine position. This techni. “ows better control of the patient's head and pen juavity to work in the ophthalmologist’ favor technique is not possible, application can be ps the slit lamp or at the bedside. Although the often cannot be performed with strict sterile t Care should be taken to keep the field as aseptic asposity. ‘A fenestrated plastic drape works well. ‘Ona side table, the tissue adhesive is opened and placa alongside sterile cotton-tipped applicators and calle Spears (e.g, Weck-cel sponges, Edward Weck Inc, NO) The wooden part of the cotton-tipped applicators then broken in half so that an angled and tapered edge i obtained. fs jagged edge remains it can be trimmed. A small ring ofaiy sterile ophthalmic ointment (e.g., erythromycin) is placed approximately 1 to 2mm from the broken edge ofthe applicator (Fig. 137.5A). When a small amount of glueis required for small perforations, the ointment is plac closer to the tip, and vice versa for larger perforations. ‘Attention is then redirected to the operating mice scope. Several drops of topical anesthetic are placed in Fig. 137.5 Technique for application cyanoacrylate tissue adhesive. A, tle ‘wooden applicator (1) with a broken, tapered, smooth end and a ring of ophthalmic ointment (2) placed approximately 1 mm from the edge. Asn drop of tissue adhesive (3) placed 00 tend ofthe applicator, the amount init by the ointment. The placement ofthe ria ointment can be modied to conte ie mount of tse achesive that wil be Gelvered to the wound. B, The patents Iying ina supine position under the open microscope withthe eyelid speculum ‘The perforation site (1) and the: ‘surrounding 1 to 2 mm have been debrided cof epithela™ and necrotic debris, The surgeon fas cellulose spear (2) in one hand and the ‘wooden applicator with the sv a G) in the other. the affected and unaffected eyes, and a Barraquer eyelid speculum Is gently inserted. The perforation site is inspected ghd ccbridement of any loose or necrotic matesial Is periormed. In addition, its extremely important to debride [to 2mm of epithelium surrounding the ulcer with a ‘cellulose spear of forceps, because glue does not adhere wel to epithelium. Any lens material, vitreous, or foreign matter present should be removed, After debridement, the perforation site should be dried thoroughly with success- fvely applied cellulose spears (Fig. 137.5B), if the wound is not completely dry, the likelihood of a satisactory adhesion is greatly diminished, If the perfor- ation site Is actively leaking aqueous, several cellulose spears may be necessary to dry the area completely. In certain situations, if not contraindicated, the anterior chamber may be gently massaged to express some aqueous so that with successive attempts at drying, aqueous does not immediately leak into the area to be glued.'* {the anterior chamber is totally flat and iris or lens {s directly beneath the perforation, a small amount of viscoelastic or air may be injected in an attempt to avoid incarceration of the tissue into the glue or additional damage to underlying structures.!* This step is difficult to achieve, especially with a flat chamber, and is not always necessary. Incarceration of tissue into the adhesive is often unavoidable and is not deemed a significant detriment to the ultimate success of the procedure. ne small drop of tissue adhesive is then carefully applied to the prepared end of the wooden applicator (Fig Fia.137.5 (Cont) €, The perforation site is dred with successively bles cellos spears just bere the application ofthe tissue ‘hese: As the gue applied to the wound, the close spear and 2opicaior are quichy removed. B, After successul application of ‘Ss adhesive (0), the perforation site Sealed. A bandage sft ‘ertact lens (2) fin place and the anterior chambers reforming 137.5). With the glue in one hand and a cellulose spear in the other, the area to be glued is quickly dried with the lp of the speat, and the glue is then inuuediately applted, (fig. 137.5C). This maneuver is accomplished by gently touching the tip with the glue directly to the perforation site and then removing it quickly. The cellulose spear should not be applied near the glued area until the adhesive has totally dried because it will stick to the glue. The glue will solidify completely within several minutes. The polymerization process can be expedited by applying a few drops of fluid (e.g,, proparacaine or preservative-free artificial tears) to the surface, but one must be careful not to displace wet glue with fluid, The goal is to fill the ulcerated area with a minimal amount of glue. The ideal amount is just enough to secure it to the surrounding comea without creating a large ring or mound of glue. Too much glue or excessive anterior protrusion of glue, which’ may cause discomfort even with a bandage contact lens, is undesirable If the entire defect is not covered or a small leak remains, additional applications of tissue adhesive to the existing plug or to an adjacent area may be necessary. Ifthe wound is still leaking and the existing plug is unsatisfactory, the slue can be removed by gently rotating it at the corneal surface and then lifting it away from the cornea. Gluing. may be reattempted, but repeated application and removal of glue may create or enlarge the defect After the adhesive solidifies, the area should be dried carefully with a cellulose spear and reinspected for an aqueous leak. If too generous an amount of glue has been, applied, any excess glue that may have become adherent 40 adjacent normal epithelialized cornea can occasionally. be removed carefully with a jeweler’s forceps. However, this ‘maneuver risks dislodging the entire plug. One additional recheck of the glued area is recommended before a bandage soft contact lens is applied. We use a loose fitting, flat, low power, low water content disposable extended wear soft contact lens such as a Optima FW, base curve 9.0mm Bausch and Lomb, Rochester, NY). If this particular lens is not available, any low water content extended wear soft contact lens with the flattest (ie., highest) base curve can be used. Unlike soft contact lenses used for other purposes, these lenses will not move significantly with blinking after ‘gluing and may have large folds with “edge off” because of surface irregularities caused by the tissue adhesive. After placement of the bandage contact lens, the ey speculum is gently removed from the eye. Depending on the clinical setting, one may sce reformation of the anterior chamber before completion of the entire procedure (Fig. 137.5D). The patient should be reexamined several minutes later to check for formation of the anterior ‘chamber and for possible dislodging of the glue or contact lens. If the glue and contact lens remain in place at the initial examination after the procedure, the patient should be rechecked 30 to 60 minutes later and once again within the next 24 hours, Small linear or curvilinear perforations may be sealed using a modification of the method described. First, glue is, applied centrally, with subsequent applications adjacent to 1676 I: 1 Surgery, tne previous glue until the entte defect is covered. There Ae Eeveralalteative techniques for application of the Aree adsives Al attempt to provide a controlled metiod der ent ofthe minimum amount of gue necessary for Placer peforauoar ste, Several other methods ac ‘Rscibea riety. Ths sts by no means exhaustive, and Set pmttioner may adopt his or her own modifications fused on personal experience ‘Sphalmie ointment may be applied to the flat end of a weoden applicator with a drop of adhesive placed on the Tayerofcintment. The glue is then directly applied to the Pfonation siteand quickly removed, Alternatively, a poly Ptnylene disk (2to 4mm in diameter) can be attached by intment tothe fla end ofa wooden applicator with glue stited to the isk "*"* Roth the gue and disk are then ieetly applied to the defect with mid pressure. Fluid siuy Be ape tothe area to expedite polymerization. The Tinlcate then removed, with the dsk in place. The disk wee pe removed gently with forceps or simply left in place Thig method has the advantage of creating a smoother ‘Rafa than vith other techniques. However, a contact lens Testi necesary for comfort. Similar variations include a Gieular piece ofa dry collagen shiek, plastic surgical drape Gr collagen. minishield (Bio Cor, Bausch and Lomb Clearwater, FL) in leu ofa polyethylene disk By apply- tng gentle pressure during application, this method allows Dobiadheaive and dsk to be applied to the depth of the defect because the disk is flexible, These methous may be particularly helpful in descemtoceles in which the surface Faibe glued has a convex anterior surface. The advantage ff a collagen shield fs that it dissolves within 24 hows Neaving a relatively smooth anterior surface to the tissue adhesive plug The tip of the plastic handle from a cellulose spear (ether flat or cut at an angle), a metal spatula," or the needle front a tuberculin syringe’ can be sed 3s an applicator, Because the latter wo applicators are made of metal, polymerization of adhesive to Uhe metalic surface may bea problem. A fine gauge capllay tube provides an titective way to control the amount of glue placed the tye Unfortunately, these tubes are no longer commonly dWallale in the United states, Alteatively, the rubber dleeve of an ISgauge IV. needle can be used to finely Control the application of gle. An angled polyethylene pipette used tn dentistry called the “Squeeze” (Ellman Ine, Hewlett, NY) hasbeen described asa superior method for application of tissue adhesive.” Biologie glues (eg. fibrin glues) have been used outside of ophthalmology for several years and nave recently been proposed for use on the comeal surface. These glues have Feveral potential advantages. They tend not to slilfy os Suichy"as cyanoacrylate gue, likely making application cer nd more accurate. Additionally, they are softer and Smoother than cyanoacrylate gue and tend to case less discomfort and fewer symptoms, Potential disadvantages tnelude the unknown length of time they remain in plac, the promation of microblal growth, and the potential human and animal produets. Fig. 137.6 Cyanoacryat tissue adhesive placed in 23 mm Pigsoration. Note the “barbell” shape ofthe glue witha lage pote eth anterior chamber (glue). In large perforations, this probleme be avoided by placing a small piece of collagen shield orcomealtsne inthe base ofthe perforation before gluing to prevent the que fom tenterng the anterior chamber, In larger perforations, a half-thickness comeal or sdenl patch® or collagen shield can be fashioned and fit int the debrided bed of the perforation or descemetocele. Ths patch is then sealed in place with tissue adhesive, using any of the aforementioned applicators. This technique his the advantage of being able to seal relatively large pet forations, limiting the chance that adhesive will ente the anterior chamber (Fig. 137.6). Postoperative management All patients should be placed on aqueous suppress consisting of either a topical beta blocker (ed, tistll 0.5% twice a day) and/or an oral carbonic anhyls inhibitor (eg., acetazolamide 500 mg sequel twice 2 or methazolamide SO mg three times a day) if medial tolerable. This regimen decreases the pressure head 3008 the perforation. Ifthe ulcer is thought to be nonin prophylactic broad-spectrum topical antibiotics uch # trimethoprim/polymyxin B, levofloxacin, gatiflox ® moxifloxacin should be used three to four times 3.0 A protective shield or glasses should be placed on the at all times, Preservative-free artificial tears should DE at least four to eight times a day to provide ations tu re nes 2 aay te Peon ee dehydrated and tight. Severely dry eyes my Te Punctal occlusion in the acute setting or at a later UH when the eye is more stable a The need for hospital admission and the use O11 venous antibiotics in the case of a sterile peHort controversial. If we are concemed about infest fencrlly admit patients and inmate Have 9 Hotics (eg, cefazolin and gentamicin of celtaidm tandard sys 5. 1m standard systemic doses for at least 48-72 hous ent is not admitted, outpatient antibiotic treatment Bit an oma fluoroquinolone (e.., ciprofloxacin, 500 mg ay levofloxacin 500 mg once a day, or moxifloxacix Jame once a day) seems most reasonable because of the sv auinolone’s excellent ocular penetration, It is also fuvprtant to check the status of the fellow eye carefully info add lubrication in this eye, if clinically indicated. Miected corneal perforations are always admitted and, ifa bacterial infection is suspected, the patient is started on fortified topical antibiotics (eg, cefazolin, 50 mg/ml, or vancomycin, 25 mg/ml, plus tobramycin, 15 mg/ml or } topical fluoroquinolone (gatifloxacin, moxifloxacin or tiprofloxacin)), every hour around the clock. These medi- «ations can be tapered appropriately over the next several 4a, depending on the clinical response and culture and sensitivity results, Antiviral or antifungal therapy should be instituted if a herpetic or fungal etiology is suspected. One must carefully balance the need for frequent topical nedications against the desire to manipulate the eye as ltleas possible, Prophylactic intravenous antibiotics may also be administered. The position of the glue and contact ware evaluated daily until discharge and then again in 5 days, If the glue and contact lens remain in place, patient may be discharged once the infection is ‘solving. Patients must be made aware that if they notice asudden change in vision, pain, discharge, photophobia, pearance of the eye, immediate follow-up necessary. tue becomes dislodged, the situation must be '. If the remaining defect can be reglued, this Id be attempted as needed. In some situ- reapplications may he necessary before a sion is obtained. Any contact lens that has ed should be replaced as soon as possible. watedly dislodges or if the resultant per- ‘oo large to repair with tissue adhesive, other penetrating keratoplasty or patch graft) slue should remain in place for weeks to somal healing and vascularization occur ‘sbilize the cornea. The contact lens should Place for as long as the glue is present to ‘ent comfort. We typically replace the bandage ‘s every 2 to 3 months, or more frequently if tact lens replacement must be performed Ne care so as not to dislodge the glue. We use an. “slum to prevent accidental eyelid closure and © of the glue. Prophylactic topical antibiotics /“thoprim/polymyxin B, levofloxacin, gatifloxacin >sscin) should be continued during contact lens

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