Detection of Infectious Corneal Perforation Using Anterior Segment Optical Coherence Tomography

Purpose: To evaluate the diagnostic performance of anterior segment optical coherence tomography (ASOCT) compared to slit lamp examination for identification of corneal perforation in microbial keratitis, and to assess ASOCT grading reproducibility. Methods: We conducted a diagnostic concordance study of 150 eyes with microbial keratitis at a tertiary eye hospital in India. Two masked graders independently evaluated ASOCT scans for perforation, with disagreements resolved by consensus. We calculated Cohen's kappa for inter-grader concordance and intra-grader repeatability. Sensitivity and specificity of slit lamp examination were calculated using ASOCT as the reference standard. Logistic regression identified factors associated with disagreement between modalities. Results: Inter-grader agreement for ASOCT was near-perfect (κ=0.98; 95% CI, 0.92-1.00). ASOCT identified perforation in 24 eyes (16.0%) compared to 12 eyes (8.0%) by slit lamp examination. Using ASOCT as reference, slit lamp examination demonstrated 33.3% sensitivity (95% CI, 14.9-52.2%) and 96.8% specificity (95% CI, 93.4-99.2%). Odds of disagreement were significantly higher for eyes with stromal thinning (OR=8.19; 95% CI, 2.27-29.54), mid-stromal involvement (OR=4.44; 95% CI, 1.08-18.30), and infection within 2mm of the limbus (OR=8.81; 95% CI, 1.77-43.80). Conclusions: ASOCT enables highly reproducible perforation grading and detects substantially more perforations than slit lamp examination, particularly in severe disease. These findings support ASOCT as an objective tool for clinical assessment and outcome ascertainment in microbial keratitis.