Mooren's Ulcer Research Articles

Corneoscleral graft in Mooren's ulcer: a case report.

IntroductionMooren's ulcer is a rare disorder of unknown etiology that is refractory to treatment. It can affect not just the cornea but also the scleral tissue and can involve both eyes.Case presentationWe report a case of a 74-year-old man with a history of bilateral and malignant Mooren's ulcer. The patient had undergone an exenteratio bulbi of the left eye because of the perforation of a Mooren's corneal ulcer. The perforated Mooren's corneal ulcer also presented in the right eye and involved the adjacent scleral tissue. It was decided to perform a corneal-scleral graft to preserve the anatomical integrity of the eye.ConclusionThis report highlights how a corneal-scleral graft followed by systemic and local immunosuppressive treatment should be considered in monocular patients with malignant Mooren's ulcer where there is serious damage to the corneal and scleral tissue.

Microtechnique of bilayer amniotic membrane transplantation for treatment of Mooren's ulcer

Objective To investigate the mierotechnique of bilayer amniotic membrane transplantation for treatment of Mooren's ulcer and evaluate the efficacy. Methods Six patients (6 eyes) with Mooren's ulcer were recruited for this study. After medical treatment or lameilar keratoplasty failed to arrest progress of corneal ulcer, bilayer amniotic membrane transplantation was performed for the treatment. We investigated the integrity of corneal epithelium, the healing of corneal ulcer, the improvement of stromal edema, the atrophy of neovessels, the transformation of amniotic membrane and the occurrence of relapse. Results All patients were followed up for 24-34 months (mean 30 months). In all cases, superficial anmiotic membrane dissolved or shed on postoperative day 7-11, disconnecting now. Corneal ulcer healed within 7-15 days postoperatively. In 5 eyes, corneal stromal edema faded away within 2-3 weeks. Corneal neovessels regressed within 2-3 months. The deeper grafts were adhered into the ulcer and fused with the cornea 3 months after the operation. Corneal transparence or macula was achieved within 5-8 months. No recurrence of Moorcn's ulcer was oc-curred in 4 patients during the follow-up period, while 2 eyes relapsed for the exposure of sutures and not re-moving the stitches timely, which had been treated with lamellar keratoplasty and no recurrence again during the follow-up period. Conclusion Bilayer amniotic membrane transplantation has advantages for Mooren's ulcer treatment. Mastering the microsurgical techniques and removing the stitches timely are the key to the success of surgery. It also provides good conditions for the further conduct of keratoplasty. Key words: Amnion; Mooren's ulcer; Transplantation; Microsurgical operation

Visual Outcome and Corneal Topography After Eccentric “Shaped” Corneal Grafts

To study the clinical and visual outcome and corneal topography in eyes that underwent full-thickness or lamellar eccentric-"shaped" (biconvex/crescentic) corneal grafts. Tertiary care center in south India. In this retrospective, interventional, noncomparative case series, eccentric-shaped corneal grafts were performed in 10 eyes (10 patients). Biconvex grafts were performed in 7 eyes, and crescentic grafts were done in 3 eyes. The indications for biconvex grafts were peripheral infected corneal ulcer (3 eyes), limbal dermoid (1 eye), squamous cell carcinoma at limbus (1 eye), rheumatoid arthritis-associated peripheral corneal melt (1 eye), and peripheral corneal perforation of unknown etiology (1 eye). Crescentic graft was performed for perforated Mooren ulcer in 3 eyes. All grafts were tectonically effective. Three grafts developed stromal haze with fine vascularization. Visual acuity was equal to or better than that before surgery in all eyes but one. This eye had deterioration in visual acuity because of progression of cataract. Corneal topography was performed in 5 eyes, which revealed corneal asymmetry but regular central corneal surface. Shaped corneal grafts for peripheral corneal diseases are tectonically viable and result in good visual outcomes.

Autologous serum for ocular surface diseases

Autologous serum has been used to treat dry eye syndrome for many years. It contains several growth factors, vitamins, fibronectin and other components that have been considered important for corneal and conjunctival integrity. Serum eye drops are usually prepared as an unpreserved blood solution. The serum is by nature well tolerated and its biochemical properties are somewhat similar to natural tears. Autologous serum eye drops have been reported to be effective for the treatment of severe dry eye-related ocular surface disorders (Sjögren's syndrome), and also other entities such as superior limbic keratoconjunctivitis, graft-versus-host disease, Stevens-Johnson syndrome, ocular cicatricial pemphigoid, recurrent or persistent corneal erosions, neurotrophic keratopathy, Mooren's ulcer, aniridic keratopathy, filtering blebs after trabeculectomy, and post-keratorefractive surgery. The purpose of this study is to review the recently published literature on ocular surface diseases treated with human autologous serum eye drops.

Outcome of Treatment of Mooren Ulcer With Topical Cyclosporine A 2%

To study the clinical outcome of treatment of Mooren ulcer with topical cyclosporine A (CsA) 2% as an adjunct to standard therapy. Seventeen eyes of 15 patients with Mooren ulcer treated with CsA 2% eyedrops were included. Five eyes had undergone a full-thickness patch graft for perforation and were started on topical CsA therapy after surgery. Topical CsA had been started in the other 12 eyes as an adjunct to standard medical therapy after treatment failure. Clinical efficacy was evaluated on the basis of reduction in lesion size, healing of the epithelial defect, visual recovery, and recurrence rate. In 12 eyes to which topical CsA had been given as an adjunct therapy, the ulcers had resolved completely with various degrees of vascularization. The mean healing time including complete epithelization was 34.4 +/- 13.1 days (range, 14-56 days). During the follow-up period of 12 months, recurrence had been observed in 1 patient. No recurrence of the ulcer was seen in the 5 eyes that were started on topical CsA therapy after tectonic keratoplasty. A significant (P = 0.004) improvement was seen in the mean best-corrected visual acuity from the pretreatment values at 12 months. No adverse effects attributable to CsA were observed. Topical 2% CsA therapy can be a safe and useful adjunct to standard medical therapy in recalcitrant cases of Mooren ulcer.

Infliximab Therapy for Aggressive Mooren Ulceration

Infliximab Therapy for Aggressive Mooren Ulceration

Mooren's Ulcer following Extracapsular Cataract Extraction

Prior cataract surgery is a recognized risk factor for the development of Mooren''s ulcer, but the demographic and clinical features of a large cohort of such patients have not been described. The authors performed a retrospective review of demographic and clinical data from 14 eyes in 13 patients who developed Mooren's ulcer following extracapsular cataract extraction at Aravind Eye Hospital in Madurai, South India. Eight (62%) of the 13 patients were men and 5 (39%) were women. The median age in our population was 65 years, with a range of 45 to 85 years. The median number of months from surgery to the onset of Mooren's ulcer was 19, with a range of 4 to 156 months. Of the 14 eyes with prior cataract surgery, the location of the ulcer was at or contiguous with the wound in 10 eyes (71%), which was 2.5 times more likely than other circumlimbal locations, and only one patient (8%) had bilateral disease. Mooren''s ulcer may occur following extracapsular cataract extraction and when it does it is most likely to be unilateral and contiguous with the wound. These findings support the notion that exposure of normally concealed corneal antigens may contribute to the pathogenesis of Mooren''s ulcer in some patients.

Management of Mooren\'s Ulcer and Visual Outcome in Jos University teaching Hospital- Central Nigeria

Background Mooren's Ulcer is a chronic painful Ulceration of the cornea, with a steep overhanging edge and may progress centrally or circumferentially to involve the whole cornea, often resulting in blindness. Aim: To review the visual outcome of Mooren's ulcer patients managed using conjunctivectomy with systemic and topical steroids in Jos University Teaching Hospital with the aim of optimizing management. Methods Case notes of patients managed in the last 5 years in Jos University teaching hospital were reviewed to ascertain the visual outcome. The folders of 19 of the 26 patients who attended the clinic were reviewed. Information on age, sex, presenting complaints, drugs used before and after presentation, examination, treatment given in JUTH and visual outcome Results The mean age at presentation was 27.7 years. Both sexes were found to be equally affected. Four (21.1%) patients had both eyes affected, 16 (66.3%) patients had used traditional eye medicines before and after presentation. Fifteen (65.2%) eyes had both medical and surgical interventions, while 8(34.8%) eyes were treated with topical and systemic steroids only. Five (21.7%) eyes had visual acuity between 6/6 to 6/18, while 3 (13.0%) eyes had visual acuity of 6/24 to 6/60. Two (8.7%) eyes had visual acuity of worse than 6/60. The final visual acuity of 13 (56.5%) eyes could not be tested after treatment because the patients were lost to follow up. Conclusion Though several studies have shown that systemic immunosuppressive chemotherapy has been found to be superior to local ocular care, such as conjunctivectomy and topical steroids, we have found that patients who did not use traditional eye medicines or indulge in self medication did well on conjunctivectomy with systemic and topical steroids. Keywords: Mooren's Ulcer, Management, and Visual OutcomeHighland Medical Research Journal Vol. 4 (2) 2006 pp. 44-48

Primary Diseases of Corneal Perforation in Shandong Province, China: A 10-Year Retrospective Study

To analyze primary diseases of corneal perforation in Shandong Province, China. Retrospective, noncomparative study. Medical records of 1,056 patients (1,080 eyes) with corneal perforation treated from January 1, 1997 through December 31, 2006 at Shandong Eye Institute were reviewed retrospectively, and primary diseases were evaluated. Corneal perforations mainly were caused by ocular trauma 715 eyes (66.8%) and infectious keratopathy 294 eyes (27.5%). In the traumatic eyes, corneal penetrating wound accounted for 608 eyes (85.0%), followed by explosion injury 42 eyes (5.9%), thermal burn 34 eyes (4.8%), and chemical injury 29 eyes (4.1%). In the infectious eyes, the most common pathogens were herpes simplex virus 124 eyes (42.2%), fungus 74 eyes (25.2%), and bacterium 20 eyes (6.8%). Repeated corneal perforation occurred in nine eyes, with primary diseases of herpes simplex keratitis (HSK; four eyes), Mooren ulcer (two eyes), necrotizing keratitis and scleratitis (one eye), bacterial keratitis (one eye), and alkali burn (one eye). Corneal grafts perforated in 31 eyes, resulting from recurrent HSK (eight eyes), implant autoproteolysis (seven eyes), bacterial infections (six eyes), recurrent Mooren ulcer (four eyes), immunologic rejection (three eyes), trauma (two eyes), and fungal recurrence (one eye). Ocular trauma and infectious keratopathy dominated among the primary diseases of corneal perforation in Shandong Province, China, during the past 10 years. HSK seems to be the most common cause of repeated corneal perforation. Recurrent primary diseases and implant autoproteolysis and infection more often result in graft perforation.

Lamellar keratoplasty for treatment of peripheral corneal perforation

To explore the indications, efficacy, and complications of different types of lamellar keratoplasty (LKP) for peripheral corneal perforation. In our nonrandomized retrospective case series, 40 cases (42 eyes) with peripheral corneal perforation at Zhongshan Ophthalmic Center between January 2003 and June 2006 underwent semi lunar LKP (14 eyes), crescent LKP (11 eyes), biconvex LKP (7 eyes), ring-shaped LKP (5 eyes), and total LKP (5 eyes). The selection of various procedures was based on the size and shape of corneal ulceration and perforation. Postoperative visual acuity (VA), corneal clarity, astigmatism, and complications were studied during a follow-up of 3 to 21 months. The initial causes and recurrence for peripheral corneal perforation were analyzed. The initial causes of corneal perforation were mostly Terrien's marginal degeneration (35.7%), Mooren's ulcer (31.0%), herpes simplex keratitis (11.9%), chemical/thermal burns (9.5%), and corneal ecstatic diseases (7. 1%). The lamellar graft attached to the host well and was transparent in 34 eyes (81.0%) following LKP. VA less than 0.1 were presented in 13 eyes (31.0%) preoperatively and in 3 eyes (7.1%) postoperatively. VA in 27 eyes (64.3%) improved after LKP, and best-corrected VA in nine eyes (21.4%) was 0.5 or better. The mean corneal astigmatism was (7.23 +/- 1.22) D three months postoperatively, and this decreased to (3.72 +/-1.76) D in six to nine months postoperatively when sutures were removed. The postoperative complications included graft-host interface effusion (8 eyes, 19.1%), secondary glaucoma (8 eyes, 19.1%) and reoccurrence of primary diseases, including Mooren's ulcer (3 eyes, 23. 1%) and herpes simplex keratitis (1 eye, 20.0%). LKP is effective to restore the integrity of the eyes with peripheral corneal perforation. Choosing the appropriate type of LKP based on different shape of corneal perforations can remove the corneal lesion and spare the normal tissue to the maximum. Moreover, the well-matched graft configuration can reduce the postoperative astigmatism, helping restore or improve the vision in most cases.

Therapeutic Keratoplasty for Corneal Perforation

To report the clinical results, postoperative progress, and complications after therapeutic keratoplasty for corneal perforation. Twenty consecutive eyes (20 patients) that underwent therapeutic keratoplasty between December 2003 and May 2006 were included. The eyes were evaluated retrospectively for the cause of the corneal perforation, the type of surgical technique and intraoperative complications, anatomic cure rates, graft clarity, visual prognosis, and postoperative complications. The causes of corneal perforation were herpetic keratitis (n = 5), bacterial ulcer (n = 1), fungal ulcer (n = 1), neurotrophic ulcer (n = 3), rheumatoid arthritis (n = 2), Mooren ulcer (n = 2), Terrien marginal corneal degeneration (n = 1), keratoconus (n = 1), and Wegener granulomatosis (n = 1). In 3 cases, the etiology was unknown. Six cases had a previous history of corneal transplantation. Anatomic cures were obtained in 16 (80%) of 20 eyes after the first transplantation procedure. Visual acuity (VA) equal to or better than the preoperative level was achieved in 17 (85%) of 20 eyes. The graft transparency rate was 67% in 15 eyes that underwent central penetrating keratoplasty with fresh donor tissue. Major postoperative complications included cataract (n = 6), glaucoma (n = 4), and recurrent disease (n = 3). Keratoplasty is valuable for maintaining the ocular integrity and VA. In cases with severe preoperative inflammation of the anterior segment, it is difficult to achieve transparency after the first graft.

The Risk Factor Analysis of Infectious Corneal Ulcers Leading to Eyeball Removal

Purpose: To determine the risk factors of corneal ulcers that require eyeball removal even when properly managed. Methods: We performed a retrospective review of 30 patients (30 eyes) who were diagnosed with corneal ulcers and underwent eyeball removal, even though their cases were properly managed, between 1990 and July, 2005. The Patients included of 14 males and 16 females. The mean age of the patients was 61.6±12.2. The ages of 20 patients were between 60 and 79. Results: Unknown (13/30 [43.4%]) was the most commonly identified predisposing factor. The other predisposing gactors were ocular trauma (10/30 [33.3%]); bullous keratopathy (3/30 [10%]); keratoplasty (1/30 [3.3%]); pterygium excision (1/30 [3.3%]); history of Mooren's ulcer (1/30 [3.3%]); and bee sting (1/30 [3.3%]). The visual acuity at the time of evisceration was LP(-) (14/30 [46.7%]); LP(+)(4/30 [13.3%]); and hand motion (12/30 [40%]). Organisms were cultured in 7 patient (23.3%). Among these patients, funguses were cultured in 4 patients, and bacteria were cultured in 3 patients. The most common causes of evisceration were perforation (13/30 [43.3%]); pain (7/30 [23.3%]); impending perforation (7/30 [23.3%]); phthisis bulbi (1/30 [3.3%]); and endophthalmitis (1/30 [3.3%]). Conclusions: According to this study, old age, ocular surface and other ocular disease and the corneal ulcer caused by fungi are the risk factor that can lead to a condition that requires removal of the eyeball. Consequently, we should pay special attention to patients who have these risk factors.

Favourable response to infliximab in a case of bilateral refractory Mooren's ulcer

A woman with progressive bilateral Mooren's ulcer developed recurrent corneal perforations and melting requiring tectonic grafts, despite conventional immunosuppressant therapy. Following treatment with infliximab, an anti-tumour necrosis factor agent, the patient showed marked reduction in conjunctival inflammation and no further recurrence of corneal thinning and perforation during 2-year follow up on maintaining treatment.

Therapeutic Effects of Tacrolimus Ointment for Refractory Ocular Surface Inflammatory Diseases

To investigate the therapeutic effects of topical tacrolimus ointment on refractory ocular surface inflammatory diseases. Retrospective interventional consecutive case series. Ten consecutive patients with severe ocular surface inflammatory diseases who were suspected to be steroid responders (elevation of intraocular pressure [IOP]) or were refractory to standard steroid therapy were studied. One patient had peripheral ulcerative keratitis with impending corneal perforation, 1 had a Mooren's ulcer, 2 had scleroperikeratitis, 5 had atopic keratoconjunctivitis, and 1 had vernal keratoconjunctivitis. The clinical findings and therapeutic responses after treatment with 0.02% topical tacrolimus ointment were determined by conventional ophthalmological examinations. Resolution of the ocular surface diseases (e.g., decrease of hyperemia, ulceration, size of papillae) and IOP. The necessity to use steroids was also assessed. In all cases, marked to moderate improvement was obtained, including suppression of the melting reaction of the inflamed cornea, remission of scleroperikeratitis, and reduction of a giant papilla and corneal epithelial defect in severe atopic keratoconjunctivitis. The elevated IOP was reduced in steroid responders after successful cessation of steroid therapy. No adverse side effect was noted for 2 to 26 months of continuous treatment. Topical tacrolimus ointment is effective in treating refractory ocular surface inflammatory diseases and should be considered as an alternative to higher doses, steroid supplementation, or surgical intervention.

Chronic hepatitis C virus infection is not associated with Mooren's ulcer

To investigate the association between chronic hepatitis C virus (HCV) infection and Mooren's ulcer. Eight patients from different parts of China who were diagnosed with Mooren's ulcer at the Zhongshan Ophthalmic Center, Guangzhou (China) were screened for chronic HCV infection. Mooren's ulcer was diagnosed by the typical ulcer morphology, detailed case history, physical examination, and comprehensive laboratory tests. All patients had serological screening for HCV infection. Six male and two female patients were enrolled in the study. Their ages ranged from 31 to 65 years (mean 43.6+/-13.7). None of them was reported to have any clinical evidence of chronic HCV infection before enrolment and all were negative for HCV serology. There was no association between chronic HCV infection and Mooren's ulcer in this limited case series study.

Autologous Serum Application in the Treatment of Mooren’s Ulcer

Mooren's ulcer is a peripheral corneal ulceration of presumed autoimmune aetiology. Its clinical course and eventual prognosis is variable and usually these ulcers respond poorly to conventional therapy. A 67-year-old male was referred to our hospital for a painful, red and tearing left eye after receiving debris. Slit-lamp examination revealed a 3.2 x 2.1 mm peripheral corneal ulcer, a diffuse thinning of the lateral limbus (between 3 o'clock and 5 o'clock) and some endothelial precipitates. The conjunctiva was severely congested. In the anterior chamber, cells (++) and fibrin were found. We introduced an antibiotic, corticosteroid and cyclosporin therapy to treat the marginal corneal deficit caused by Mooren's ulcer. The patient did not respond to the initial treatment, but re-epithelialisation occurred and the corneal deficit improved after the introduction of autologous serum eye drops. Autologous serum seems to be an effective supplementary therapy in Mooren's ulcer.

Récurrence d’un ulcère de Mooren après une chirurgie de la cataracte

We report the case of Mooren's ulcer recurrence after uncomplicated cataract surgery in a 61-year-old woman. This cataract developed because of repetitive inflammation of the anterior chamber and corticotherapy. Local and general corticotherapy with cyclosporin 2% drops was started in association with an anterior lamellar graft and a conjunctival recession due to a preperforation condition. Secondarily cyclophosphamide was necessary to control recurrence with a good anatomic result and an increase in visual acuity. The case updates physiopathologic and diagnostic data on this rare limbic autoimmune ulcerative disease. The diagnosis was made by histology and the dosage of specific autoantibodies against cornea. The prevention of recurrence after surgery requires a long clinical quiescent period, minimally invasive surgery long after inflammation has subsided, and a gradual tapering of corticotherapy over several weeks.

Amnionmembrantransplantation und hoch dosiertes systemisches Ciclosporin A (Sandimmun optoral®) bei Ulkus Mooren

Mooren's ulcer is a rare, severe corneal autoimmune inflammation leading to blindness if treated insufficiently. High-dose systemic cyclosporin A (Sandimmun optoral) was shown to markedly reduce inflammation and stop corneal destruction. We report on three cases in which this immunosuppressive regimen required additional AM transplantation for complete healing. One 37-year-old male (M) and two 49- (F1) and 58-year-old females (F2) presented with unilateral Mooren's ulcer in different stages of the disease, which deteriorated despite high-dose systemic cyclosporin A (Sandimmun optoral M, F1) or treatment with topical cyclosporin A 2 % (F2). After surgical removal of all grossly affected corneal stroma, amniotic membrane was made to cover the entire cornea and fixed with episcleral sutures in two patients (M, F2). In one patient (F1) a deep marginal ulcer was covered with a fitted AM glap. All patients were treated postoperatively up to 6 months with high-dose systemic cyclosporin A (Sandimmun optoral). Blood trough levels aimed at 150 to 200 ng/mL. Topical cyclosporin A was administered in addition in two patients (M, F2) postoperatively for at least 6 months. Due to incompatibility, one patient (F1) was treated with topical steroids instead. Follow-up time was 42 months (M), 50 months (F1) and 54 months (F2). All three eyes exhibited clinical healing with stable corneal surfaces thereafter. Depending on the stage of Mooren's ulcer at the time of surgery, visual acuity remained at hand motions in one patient (M) and recovered to 1.0 and 0.6, respectively, in two patients (F1, F2). Due to its anti-inflammatory potential, coverage by AM seems to trigger a therapeutic turnaround in cases of Mooren's ulcer which do not heal with intensive immunosuppressive regimens alone. In order to maintain or restore as much visual function as possible, additional amniotic membrane surgery should be performed early enough in the course of the disease.

Treatment of Mooren’s Ulcer with Topical Administration of Interferon Alfa 2a

To report an apparently beneficial effect of topical interferon alfa 2a (IFNalpha2a) as a single therapeutic agent in the treatment of Mooren's ulcer. Two case reports. Two consecutive patients with unilateral Mooren's ulcer diagnosed at the cornea service of Gulhane Military Medical Academy from December 2004 to December 2005 were studied retrospectively. Patients with a clinical diagnosis of Mooren's ulcer were treated with topical IFNalpha2a until their lesions resolved. A review of medical records was performed to assess the duration and response to treatment with topical IFNalpha2a drops, defined by clinical resolution of Mooren's ulcer. Symptoms and signs in 2 eyes improved during the first week of treatment, and reepithelialization was achieved at 7 and 10 days. Visual acuity levels reached 20/25 and 20/30 within 1 month of treatment. No recurrences were observed during 1 year and 6 months of follow up. Topical IFNalpha2a as a single therapeutic agent was an effective alternative in the treatment of our 2 patients with Mooren's ulcer. It offers the benefits of topical therapy and avoided surgical or other interventions that may lead to stem cell deficiency. Larger controlled studies are necessary to confirm the long-term efficacy and safety of this treatment.

Hookworm Infestation as a Risk Factor for Mooren’s Ulcer in South India

To investigate the association between Mooren's ulcer and intestinal hookworm infestation in South India. Prospective observational case-control study. Fifteen patients with Mooren's ulcer and 30 age- and gender-matched controls seen at Aravind Eye Hospital. Stool samples from the Mooren's ulcer patients and controls were collected and analyzed for presence of hookworm infestation. Prevalence of hookworm infestation in Mooren's ulcer patients and controls. There was a statistically significant correlation between intestinal hookworm infestation and the occurrence of Mooren's ulcer (P = 0.009). Retrospective exploratory subgroup analyses suggested that the correlation between intestinal hookworm infestation and the occurrence of Mooren's ulcer in men (P<0.0001) was stronger than the correlation in women, with no statistically significant difference being observed in the prevalence of hookworm infestation between women with Mooren's ulcer and female control subjects (P>0.99). Similarly, when both the Mooren's ulcer and the control subject groups were analyzed retrospectively by age > 50 years or age < 50, subjects with an age over 50 demonstrated a stronger correlation between hookworm infestation and Mooren's ulcer than controls (P = 0.017), whereas there was no statistically significant difference in the prevalence of hookworm infection between Mooren's ulcer subjects and control subjects < or = 50 (P = 0.31). Intestinal hookworm infestation appears to be associated with the development of Mooren's ulcer in South India. Although the power of our retrospective exploratory subgroup analyses was limited by multiple testing and small sample sizes, these data suggest further that the correlation between intestinal hookworm infestation and the development of Mooren's ulcer may be greatest in male patients with more advanced age.