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    Expert tips for surgically managing corneal perforations


    As one sign that an ulcer may have resulted from an autoimmune process, Dr. Tuli recommended looking for a shelf of epithelium “almost like an excavation.” Infectious ulcers by contrast “look more like a bowl,” she said.

    Autoimmune ulcers tend to be peripheral, whereas infectious ulcers are more likely to be central, since blood vessels at the periphery of the cornea can provide better protection from infection.

    Whatever causes the initial insult, resulting stromal tissue loss can lead to a desemetocele. Minor trauma or straining can then rupture the desemetocele.

    Clinicians may want to treat the underlying cause of the ulcer, for example using such protease inhibitors as tetracylines and vitamin C, or in the case of a bacterial infection, with topical and systemic antibiotics. Vitamin C benefits white blood migration and helps tetracycline to inhibit proteases, Dr. Tuli said. Steroid drops can suppress the inflammation.

    “If it’s autoimmune, you need to suppress the immune system,” she said. “So typically we’ll put them on high-dose steroids and send them to a rheumatologist to put them on systemic immunosuppressants.”

    If the cause is trauma, and the tissue loss is mostly linear and minimal, the clinician can attempt primary closure with sutures. However, this approach involves a high risk of leaks and gapes and can result in significant postoperative astigmatism.

    “You’ll have to crank the sutures down,” Dr. Tuli explained. “That could cause the cornea to buckle and change shape. Sometimes when you take the stitches out, it does recover, but often if there is any tissue loss at all, it’s permanent.”

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