The aim of this review was to report the existing literature on the incidence, risk factors, treatment, and outcomes of scleral perforation as a vision-threatening complication of strabismus surgery. The current literature reported an incidence range of scleral perforation/penetration between 3 in 1,000 and 7.8%. Rectus muscle recession was the most commonly mentioned risk factor among the studies. Other risk factors were myopia, previous extraocular muscle surgery, surgeon experience, S-24 needle use, muscle reattachment posterior to the original insertion site, operating on a horizontal rectus muscle, and young age. Different views existed in the literature regarding scleral perforation management. Some ophthalmologists advocated management by cryopexy or indirect ophthalmoscopic laser uniformly, whereas others reserved it for more complicated cases. Antibiotic therapy for endophthalmitis prophylaxis was recommended by one study and shown to be practiced by some ophthalmologists. [J Pediatr Ophthalmol Strabismus. 2022;59(4):214-223.].