Corneal thinning and perforation: a narrative review of diagnostic and stepwise management strategies

Corneal perforation is a sight-threatening ophthalmic emergency caused by trauma, infection, autoimmune disease, or ocular surface disorders. Early recognition and timely management are critical to maintain globe integrity and prevent complications. This review synthesizes current knowledge on the diagnosis and management of corneal perforations.

A narrative review of the literature was conducted using PubMed, Scopus, Web of Science, and Google Scholar through 2025. Keywords included "corneal perforation," "corneal thinning," "corneal melt," "ulcerative keratitis," "tissue adhesive," "amniotic membrane transplantation," and "keratoplasty." English-language original studies, case series, and reviews were included, and unrelated reports were excluded. Data were qualitatively synthesized due to heterogeneity in study designs. Illustrative clinical cases from King Khaled Eye Specialist Hospital were included to demonstrate real-world diagnostic and therapeutic approaches.

Major causes of corneal perforation include infectious keratitis, autoimmune/inflammatory diseases, neurotrophic keratopathy, trauma (including iatrogenic), and degenerative or exposure-related conditions. Common clinical features are rapid vision loss, severe ocular pain, and tearing. Evaluation requires a careful, minimally manipulative examination with adjunctive imaging and systemic assessment when indicated. Management options include tissue adhesives, amniotic membrane grafts, platelet-rich plasma, lamellar or penetrating keratoplasty, and conjunctival flaps. Recent advances in biological adhesives, amniotic membrane techniques, and anterior segment imaging have expanded treatment options and improved outcomes. Follow-up is guided by slit lamp examinations and imaging.

This review integrates recent evidence and evolving strategies to provide clinicians with a structured, stepwise framework for managing corneal perforations.