Purpose <p>This study aimed to report the incidence, characteristics, and prognosis of corneal perforation in patients with leprosy.</p> Study design <p>Retrospective observational study.</p> Methods <p>Patients who presented with leprosy and visited a specialised ophthalmology hospital (Miyata Eye Hospital, Miyazaki, Japan) between 1980 and 2020 were included. Their medical charts were retrospectively reviewed, and the incidence of lagophthalmos and corneal perforation was examined. Additionally, the presentation, treatment, and prognosis of patients with corneal perforations were assessed.</p> Results <p>In total, the records of 472 eyes of 236 patients (128 men and 108 women; mean age, 81.2 ± 7.5 years) diagnosed with leprosy were reviewed. Forty-one patients were diagnosed with lagophthalmos, and two of these patients (4.8%) showed signs of corneal perforation. Patients with lagophthalmos presented significantly more frequently with cicatricial contraction of eyelids (<i>p</i> &lt; 0.001), superficial punctate keratopathy (<i>p</i> &lt; 0.001), epithelial defect (<i>p</i> = 0.039), and corneal ulcer (<i>p</i> &lt; 0.001) compared with patients without lagophthalmos. Patients with corneal perforation had uveitis more frequently compared with those without corneal perforation (<i>p</i> = 0.01).</p> Conclusion <p>Patients with leprosy frequently develop lagophthalmos. Patients with uveitis associated with leprosy are especially at risk of corneal perforation.</p>