Mooren's Ulcer Research Articles

Peripheral ulcerative keratitis in association with sarcoidosis

Peripheral ulcerative keratitis (PUK) is a sight-threatening condition characterized by an epithelial defect, crescent-shaped stromal inflammation, and progressive stromal thinning. Peripheral ulcerative keratitis as a purely inflammatory entity is most commonly associated with collagen vascular diseases, including rheumatoid arthritis, polyarteritis nodosa, Wegener granulomatosis, systemic lupus erythematosus, and relapsing polychondritis. PUK can also be associated with infectious and inflammatory conditions such as hepatitis, syphilis, herpes simplex keratitis, fungal keratitis, Mooren ulcer, and marginal keratitis. We describe a case report of PUK associated with the inflammatory condition of sarcoidosis.

Sterile corneal perforations in a case of severe dry eyes

Sterile corneal ulcers and perforations can occur as a result of eye injury, Mooren's ulcer etc as an isolated ocular problem or they may be associated with various collagen vascular or other autoimmune diseases. Recurrent corneal erosions, exposure keratitis, neurotrophic keratitis, keratomalacia that affect the integrity of the ocular surface epithelium may also sometimes result in the development of sterile corneal ulcers.1Sterile corneal ulceration is a serious complication in patients with keratoconjunctivitis sicca.1–4 The common etiologies of dry eyes leading to corneal perforation include Sjogren's syndrome, rheumatoid arthritis, ocular pemphigoid, atopy and local irradiation.2–4 We report an uncommon case of sterile corneal perforation in severe dry eye without any underlying systemic cause.

Immunosuppression for Mooren's ulcer: evaluation of the stepladder approach—topical, oral and intravenous immunosuppressive agents

AimTo evaluate a step ladder approach for immunosuppressive regimen for Mooren's ulcer.Material and methodsWe retrospectively analysed patients of Mooren's ulcer presenting to a tertiary care centre in south India from...

Application for Tacrolimus Ointment in Treating Refractory Inflammatory Ocular Surface Diseases

To evaluate the therapeutic effects of topical tacrolimus ointment on refractory inflammatory ocular surface diseases. Retrospective interventional consecutive case series. In Severance Hospital, Seoul, South Korea, 0.02% tacrolimus ointment was topically applied 1 to 3 times per day, depending on disease severity, for up to 31 months in eyes of 12 consecutive patients with refractory inflammatory ocular surface diseases who had previously been treated with steroid therapy. Seven patients had chronic cicatrizing conjunctivitis (6 cases caused by Stevens-Johnson syndrome and 1 attributable to ocular cicatricial pemphigoid); 4 had scleritis (3 necrotizing scleritis, 1 recurrent nodular scleritis); and 1 patient had Mooren ulcer with corneal perforation. The therapeutic outcomes after tacrolimus treatment were evaluated according to the following criteria: change in clinical findings (eg, decrease of hyperemia, ocular pain, epithelial defect, and pseudomembrane), intraocular pressure (IOP), and need for steroid therapy. In all 3 groups, tacrolimus showed an immunosuppressive effect, especially on scleritis and Mooren ulcer. These effects included suppression of corneoscleral melting and reduction of hyperemia. In chronic cicatrizing conjunctivitis, simultaneous topical tacrolimus while tapering steroid therapy suppressed inflammatory relapse. The elevated IOP in steroid responders recovered to normal range after successful tapering of steroid. No adverse side effects were noted after 1.5 to 31 months of continuous tacrolimus treatment. The use of topical tacrolimus ointment is effective in controlling refractory inflammatory ocular surface disease, and can reduce the need for steroid use while reducing inflammation recurrence.

Immunohistochemical analysis of inflammatory limbal conjunctiva adjacent to Mooren's ulcer

Background/aimsTo examine the characteristics of infiltrating cells in conjunctival tissues adjacent to the peripheral corneal ulcers of Mooren's ulcer.MethodsThis study involved four eyes of four patients with Mooren's ulcer and...

Severe unilateral corneal melting after uneventful phacoemulsification cataract surgery

We present a rare case of severe unilateral corneal melt after uneventful phacoemulsification. A 38‐year‐old woman presented one week after uneventful phacoemulsification cataract surgery complaining of pain and blurred vision in her operated eye. Our differential diagnosis included peripheral ulcerative keratitis, Mooren's ulcer and herpetic keratitis. The patient was started on oral acyclovir and topical steroids. An extensive blood work‐up was done to rule out autoimmune diseases. Purified protein derivative test demonstrated 15 mm of erythema. Because the clinical picture was progressing, the patient was started on triple anti‐tuberculosis therapy. Despite treatment, the patient was complaining of excruciating eye pain that was relieved only with intramuscular prednisone injections. The corneal melt healed after approximately three months without any other intervention, leaving a 90 per cent thickness loss in its central area. Idiopathic corneal melt after uneventful phacoemulsification is a rare complication, which must be managed in a multidirectional treatment approach to prevent devastating corneal perforation.

Mooren Ulcer Occurring at Donor Site After Contralateral Conjunctivolimbal Autograft for Recurrent Pterygium

Mooren Ulcer Occurring at Donor Site After Contralateral Conjunctivolimbal Autograft for Recurrent Pterygium

Severe corticoresistant Mooren Ulcers: management with Rituximab and peripheral lamellar graft

AbstractPurpose Mooren's ulcer is a rapidly progressive, painful, ulcerative keratitis which affects the peripheral cornea. We report 6 severe cases of Mooren Ulcers (4 patients) with corticoresistance favourably responding to Rituximab infusions.Methods Retrospective Case seriesResults Despite systemic intensive steroid (4/4 patients), and Cyclophosphamide (2/4 patients) therapy, the 6 cases of Mooren’s ulcers progressively spread circumferentially and centrally. Perforation occurred in 4/6 affected eyes, treatment included conjunctival resection and peripheral corneal graft. Rituximab biotherapy was associated with the stabilisation and the healing of the corneal lesions. Systemic steroid therapy was tapered then stopped in all patients within 2‐4 months following rituximab therapy.Conclusion Rituximab, an anti‐CD20 monoclonal antibody, has been successfully used off‐label for treatment of Severe corticoresistant Mooren’s Ulcer.

Bilateral Mooren’s ulcer in a child secondary to helminthic infestation of the gastrointestinal tract

To report an unusual association of bilateral Mooren's ulcer in a child with helminthic infestation of gastrointestinal tract. A 6-year-old female presented with redness, watering and photophobia in left eye for 2months and in right eye for 2weeks. BCVA was 20/200 in OD and 20/400 OS. Superior peripheral corneal ulcer of 8×2mm was present in the right eye and 8×3mm perforated limbal corneal ulcer with staphyloma was present in the left eye. Hemogram revealed microcytic hypochromic anemia, eosinophilia and elevated ESR. No organism was isolated on corneal scraping. Stool examination revealed presence of Ancylostoma duodenale. Therapy included fortified topical antibiotics, cycloplegics, lubricants and oral albendazole. Conjunctival recession and crescentic therapeutic penetrating keratoplasty was done in OD and OS respectively. At 18months follow up, there was no recurrence in any of the eyes. Bilateral Mooren's ulcer may be present with gastrointestinal hookworm infestation. Prompt and appropriate management may provide optimal therapeutic success.

Adalimumab for refractory peripheral ulcerative keratitis

Peripheral ulcerative keratitis (PUK) is an immune-mediated disorder characterized by patchy, peripheral stromal thinning and infiltrates which tend to coalesce and extend to the limbus and often the sclera (unlike Mooren's ulcer) even in the presence of an intact overlying epithelium [1]. PUK is usually associated with systemic disorders such as rheumatoid arthritis, inflammatory bowel disease, or panarteritis nodosa among others. Adalimumab is a human monoclonal antibody against tumor necrosis factor-alpha (TNF-α) that has demonstrated substantial efficacy when used for the treatment of several immune-mediated diseases [2, 3]. We describe two patients with refractory unilateral PUK associated with different systemic conditions who were successfully controlled with adalimumab for at least 1 year.

Mooren's ulcer in children

PurposeTo describe the epidemiology, clinical features, management and outcomes of paediatric Mooren's peripheral ulcerative keratitis.MethodsAll patients with Mooren's ulcer aged <18 years presenting at a single centre from 1987 to...

Surgical excision of corneal and coniunctival lesions combined with cryotherapy in the treatment of Mooren's ulcer

Objective To discuss the efficacy of surgical excision of corneal and conjunctival lesions combined with carbon dioxide cryotherapy for the treatment of Mooren's ulcer.Methods 16 cases ( 17eyes) were underwent surgical excision of corneal lesions and conjunctival tissues adjacent to ulcer,followed with carbon dioxide cryotherapy,immunosuppressive agents were administered until the ulcer healed.All the cases were followed up for 1 to 5 years.Results None of the cases had infection and deterioration during therapy.7 cses (7 eyes) cured after combined therapy once,cryotherapy 4cases(4eyes) cured after repeated carbon dioxide cryotherapy 4cases (4 eyes) appeared to recurrent attacks,yet no recurrence was detected after repeated combined therapy.2 eyes appeared to recurrent attacks,and accepted the corneoscleral lamellar graft.Conclusion The surgical excision of corneal and conjunctival lesions combined with cryotherapy is effective to treat Mooren's ulcer.The key procedure is excising the lesion tissues completely and mastering the appropriate temperature,time and frequency in cryotherapy. Key words: Corneal ulcer,Mooren's; Surgical excision; Cryocoagulation

Expression of prostaglandin E receptor subtype EP4 in conjunctival epithelium of patients with ocular surface disorders: case-control study

ObjectivesTo confirm the downregulation of PTGER4 mRNA in the conjunctiva of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) and ocular cicatricial pemphigoid (OCP) patients and to examine the expression of its EP4...

Mooren′s corneal ulceration in a pseudophakic eye: A case report and literature review

Surgery (ECCE+ PCIOL) is an unusual possible aetiology of Mooren's corneal ulceration. A clinical and laboratory evaluation of a case of a 60-year-old male Nigerian who in the immediate postoperative period developed Mooren's corneal ulceration after an uneventful extracapsular cataract extraction and a posterior chamber intraocular lens (ECCE+PCIOL) implantation at an outreach center is presented. Healing occurred within 2 weeks of medical and surgical intervention, but no remarkable visual improvement. A review of literature from relevant sources with emphasis on management options is also incorporated. Many cases of Mooren's corneal ulceration remain refractory to treatment even in advanced countries. However, early case finding and prompt referral by trained primary eye care personnel may help to reduce severe visual morbidity in this environment.

Anesthetic keratopathy presenting as bilateral Mooren-like ulcers

This observational case report describes the development of bilateral Mooren-like ulcers in a patient with anesthetic keratopathy. A 42-year-old man with a recent history of minor eye trauma and pain self-treated with tetracaine eye drops presented with complaints of acutely worsening vision and severe pain bilaterally. His visual acuity at presentation was limited to hand motion. Slit-lamp examination revealed bilateral epithelial defects at the center of the cornea, and an area of stromal infiltration and thinning with an undermining leading edge resembling a Mooren’s ulcer in both eyes. Corneal haze and hypopyon were visible. Anesthetic use was halted immediately and the patient was started on prednisolone and mycophenolate mofetil (Cellcept®), after which visual acuity gradually improved and pain decreased. Despite improvement of symptoms, residual epithelial defects remained, and the patient was ultimately treated with keratoplasty for recovery of vision. We suggest that anesthetic keratopathy should be included in the differential diagnosis for any patient presenting with ring-shaped stromal infiltrates or nonhealing epithelial defects.

Prostaglandin E Receptor Subtype EP3 Expression in Human Conjunctival Epithelium and Its Changes in Various Ocular Surface Disorders

BackgroundIn our earlier genome-wide association study on Stevens-Johnson Syndrome (SJS) and its severe variant, toxic epidermal necrolysis (TEN), we found that in Japanese patients with these severe ocular surface complications there was an association with prostaglandin E receptor 3 (EP3) gene (PTGER3) polymorphisms. We also reported that EP3 is dominantly expressed in the ocular surface-, especially the conjunctival epithelium, and suggested that EP3 in the conjunctival epithelium may down-regulate ocular surface inflammation. In the current study we investigated the expression of EP3 protein in the conjunctiva of patients with various ocular surface diseases such as SJS/TEN, chemical eye burns, Mooren’s ulcers, and ocular cicatricial pemphigoid (OCP).Methodology/Principal FindingsConjunctival tissues were obtained from patients undergoing surgical reconstruction of the ocular surface due to SJS/TEN, chemical eye burns, and OCP, and from patients with Mooren's ulcers treated by resection of the inflammatory conjunctiva. The controls were nearly normal human conjunctival tissues acquired at surgery for conjunctivochalasis. We performed immunohistological analysis of the EP3 protein and evaluated the immunohistological staining of EP3 protein in the conjunctival epithelium of patients with ocular surface diseases. EP3 was expressed in the conjunctival epithelium of patients with chemical eye burns and Mooren’s ulcer and in normal human conjunctival epithelium. However, it was markedly down-regulated in the conjunctival epithelium of SJS/TEN and OCP patients.ConclusionsWe posit an association between the down-regulation of EP3 in conjunctival epithelium and the pathogenesis and pathology of SJS/TEN and OCP, and suggest a common mechanism(s) in the pathology of these diseases. The examination of EP3 protein expression in conjunctival epithelium may aid in the differential diagnosis of various ocular surface diseases.

The Application of In Vivo Confocal Scanning Laser Microscopy in the Diagnosis and Evaluation of Treatment Responses in Mooren's Ulcer

To evaluate the extent of corneal inflammation and the response to treatment in patients with Mooren's ulcer, by in vivo confocal microscopy (IVCM). Twenty-two eyes of 15 patients with Mooren's ulcer were enrolled in this prospective study. All subjects underwent routine ophthalmic examinations, IVCM, and conjunctival histopathologic examination of specimens in patients undergoing conjunctival excision. Eyes with active ulcer were treated with topical corticosteroids and additional therapy, depending on the signs and symptoms. Eyes in remission continued to receive the previous treatment protocols. The relation between the severity of ulcer and inflammation status as assessed by IVCM was also studied. The endpoints were inflammatory cell density (ICD), counted by IVCM, and the extent of the limbal arc involved with ulcers. Ten eyes had active corneal ulcers, and 12 eyes had been in remission for the past year. The mean ICD of eyes with active ulcers before treatment was 2092.7 ± 1538.6 cells/mm(2) (range, 835.3-7832.7; 95% CI, 3232.5-952.9). Nine of the eyes improved at 8 weeks, with a decrease in ICD to 249.1 ± 109.0 cells/mm(2) (range, 100.3-595.3; 95% CI, 329.8-168.3). One eye had corneal perforation, and ICD immediately before perforation was 1677.6 ± 247.6 cells/mm(2). The mean ICD of 12 eyes in remission was 357.5 ± 266.8 cells/mm(2) (range, 12.7-1127.0; 95% CI, 555.2-159.8). The correlation of the ICD and the extent of limbal involvement with ulcers was strong (R(2) = 0.8119). ICD evaluated by IVCM is a useful and promising parameter for evaluation of the degree of inflammation in eyes with Mooren's ulcer and for assessment of response to treatment.

Mooren's ulcer and amniotic membrane transplant: a simple surgical solution?

Mooren's ulcer and amniotic membrane transplant: a simple surgical solution?

Surgical removal of eyes in a tertiary institution in North eastern Nigeria

Background Surgical eye removal is performed for various end-stage eye diseases to provide adequate comfort, replace volume and give good functional and cosmetic appearance. The pattern of eye removal is unknown for North Eastern Nigeria. Objective To determine the indications for eye removal in the study community. Method Records of all the patients whose eyes were removed between January 2002 and December 2008 were reviewed retrospectively. Age, sex, diagnosis and type of surgery were recorded. Results A total of 67 eyes were removed during the period consisting of 46 males (68.7%). Mean age was 29.5 years (range 4 months to 90 years). Indications for surgery were trauma, 26 (38.8%), infection, 21 (31.3%), anterior staphyloma, 14 (20.9%), tumor 4, (6.0%) and painful blind eye, 2 (3.0%). Evisceration was performed in 55 (82.1%), enucleation, 11 (16.4%) and exenteration, 1 (1.5%) patient. In children (n = 28), the indications were trauma and anterior staphyloma in 10 patients (35.7%) each, tumor in 4 (14.3%), infection in 3 (10.7%) and painful blind eye (mooren's ulcer) in 1 (3.6%) of the children respectively. In adults (n = 39), indications were infections, 18 (46.2%), trauma, 16 (41.0%), anterior staphyloma, 4 (10.3%) and painful blind eye due to advanced glaucoma, 1 (2.6%). Conclusion Trauma, infections, and anterior staphyloma were the major indications for eye removal. Most of the indications were avoidable.

Boston type 1 keratoprosthesis for severe blinding vernal keratoconjunctivitis and Mooren’s ulcer

Indications for the Boston keratoprosthesis differ throughout the world depending on the prevailing regional causes of end-stage corneal disease. We report the short term anatomical and functional outcomes of the Boston type 1 keratoprosthesis for severe bilaterally blinding vernal keratoconjunctivitis and Mooren's ulcer. A retrospective chart review was conducted of 2 patients who underwent several unsuccessful ocular surface reconstruction procedures before Boston type 1 keratoprosthesis implantation. The anatomical and visual outcomes of the Boston type 1 keratoprosthesis at 1year of follow-up were assessed clinically and by anterior segment optical coherence tomography imaging. The keratoprosthesis was retained in both the eyes at 1year postoperatively with a best-corrected visual acuity of 20/30 in both patients. To our knowledge this is the first report of successful Boston keratoprosthesis implantation for these two unusual indications.