Mooren-type hepatitis C virus-associated corneal ulceration

Demographic Characteristics, Clinical Presentations, and Risk Factors Impacting Visual Outcomes in Peripheral Ulcerative Keratitis

PURPOSE

To assess the demographic characteristics, ophthalmic and systemic presentations, and risk factors impacting the outcomes in patients diagnosed with peripheral ulcerative keratitis (PUK).

METHODS

This retrospective study includes patients diagnosed with PUK at a tertiary care center over 13 years. A descriptive analysis of the demographics, clinical history, and presentation was performed. A reverse risk analysis was performed to assess the PUK resolution in patients with underlying autoimmune and non-autoimmune etiologies. Finally, we evaluated the correlation between treatment duration and final best corrected visual acuity (BCVA) and continuous and categorical variables.

RESULTS

A total of 58 eyes of 51 patients with a mean age of 59.67 ± 13.41 years diagnosed with PUK were included in the study; 58.82% were female. The resolution duration was significantly shorter in patients with autoimmune etiologies (vs. non-autoimmune etiologies, P = 0.028) and female patients (vs. male patients, P = 0.008). The BCVA worsened in patients with non-autoimmune etiologies after treatment ( P = 0.17). Despite worse BCVA at presentation in patients with underlying autoimmune etiologies, significantly better final vision outcomes were observed ( P = 0.04). Linear regression analysis showed that longer treatment duration ( P = 0.001; R 2 = 0.1704) and worse vision ( P = 0.002; R 2 = 0.1502) at presentation were the primary risk factors of poor vision outcomes. Similarly, the treatment duration was significantly longer in male compared with female patients ( P < 0.001; R 2 = 0.2027).

CONCLUSIONS

The clinical outcomes in PUK with underlying autoimmune disorders were observed to be better than non-autoimmune etiologies, which may be attributed to the early detection of the PUK-related changes and aggressive medical management. A delayed diagnosis of PUK leads to poor vision outcomes.

Ocular manifestations of liver disease: an important diagnostic aid

PURPOSE

This review examined existing literature to determine various ocular manifestations of liver pathologies, with a focus on metabolic deficiencies as well as viral and immune liver conditions.

METHODS

Recent data were compiled from PubMed from 2000 to 2020 using keywords that were relevant to the assessed pathologies. Ocular presentations of several liver pathologies were researched and then summarized in a comprehensive form.

RESULTS

Several ocular manifestations of liver disease were related to vitamin A deficiency, as liver disease is associated with impaired vitamin A homeostasis. Alcoholic liver cirrhosis can result in vitamin A deficiency, presenting with Bitot spots, xerosis, and corneal necrosis. Congenital liver diseases such as mucopolysaccharidoses and peroxisomal disorders are also linked with ocular signs. Viral causes of liver disease have associations with conditions like retinal vasculitis, keratoconjunctivitis sicca, retinopathies, Mooren's ulcer, and Sjogren's syndrome. Autoimmune hepatitis has been linked to peripheral ulcerative keratitis and uveitis.

CONCLUSIONS

Building strong associations between ocular and liver pathology will allow for early detection of such conditions, leading to the early implementation of management strategies. While this review outlines several of the existing connections between hepatic and ophthalmic disease, further research is needed in the area in order to strengthen these associations.

Interleukin-1 and Transforming Growth Factor Beta: Commonly Opposing, but Sometimes Supporting, Master Regulators of the Corneal Wound Healing Response to Injury

Purpose

Interleukin (IL)-1α/IL-1β and transforming growth factor (TGF)β1/TGFβ2 have both been promoted as “master regulators” of the corneal wound healing response due to the large number of processes each regulates after injury or infection. The purpose of this review is to highlight the interactions between these systems in regulating corneal wound healing.

Methods

We conducted a systematic review of the literature.

Results

Both regulator pairs bind to receptors expressed on keratocytes, corneal fibroblasts, and myofibroblasts, as well as bone marrow-derived cells that include fibrocytes. IL-1α and IL-1β modulate healing functions, such as keratocyte apoptosis, chemokine production by corneal fibroblasts, hepatocyte growth factor (HGF), and keratinocyte growth factor (KGF) production by keratocytes and corneal fibroblasts, expression of metalloproteinases and collagenases by corneal fibroblasts, and myofibroblast apoptosis. TGFβ1 and TGFβ2 stimulate the development of myofibroblasts from keratocyte and fibrocyte progenitor cells, and adequate stromal levels are requisite for the persistence of myofibroblasts. Conversely, TGFβ3, although it functions via the same TGF beta I and II receptors, may, at least in some circumstances, play a more antifibrotic role—although it also upregulates the expression of many profibrotic genes.

Conclusions

The overall effects of these two growth factor-cytokine-receptor systems in controlling the corneal wound healing response must be coordinated during the wound healing response to injury or infection. The activities of both systems must be downregulated in coordinated fashion to terminate the response to injury and eliminate fibrosis.

Translational Relevance

A better standing of the IL-1 and TGFβ systems will likely lead to better approaches to control the excessive healing response to infections and injuries leading to scarring corneal fibrosis.

Peripheral ulcerative keratitis

Peripheral ulcerative keratitis (PUK) is an inflammatory condition of the peripheral cornea with hallmark features of epithelial defects and stromal destruction as a result of a complex interplay of factors including host autoimmunity and the peculiar anatomic and physiologic features of the peripheral cornea and environmental factors. PUK may be the result of local or systemic causes and infectious or noninfectious causes. Arriving at a specific etiological diagnosis requires a meticulous clinical workup that may include a battery of laboratory and radiological investigations. Management by a team of internists or rheumatologists and ophthalmologists and judicious use of immunosuppressive agents may yield favorable results minimizing adverse effects. We review current clinical knowledge on the diagnosis and management of PUK.

Biology of peripheral ulcerative keratitis

Peripheral ulcerative keratitis (PUK) is a progressive peripheral thinning of the corneal stroma caused by proinflammatory mediators' release from corneal limbal vasculitis. The clinical presentation is an epithelial defect with a crescent-shaped stromal inflammation. Its exact pathophysiologic mechanisms of PUK remain partially understood, but the overall understanding of the fundamental processes that mediate and effect corneal immunity has continued to expand over the past 25 years. The unique anatomical and physiological characteristics of the periphery in relation to collagen bundles and peripheral corneal vascular arch contribute to the occurrence of this type of ulcer in this region, in addition to the concentration of complement and immunoglobulins. There is a relevant participation of the adjacent conjunctiva. Both cell-mediated immunity and humoral immunity are implicated in the pathogenesis of PUK, and the postulated mechanisms are autoimmune reactions to corneal antigens, deposition of circulating immune complexes and hypersensitivity reactions to foreign antigens. These immunocomplexes are deposited in limbic vessels resulting in the activation of the classical pathway of the complement system and, consequently, in the chemotaxis of inflammatory cells and in the release of several pro-inflammatory cytokines, which allow the production and release of matrix metalloproteinases. The release of inflammatory cytokines by infiltrating cells may induce keratocyte activation, which could then generate more release of a variety of cytokines, such as the neutrophil calgranulin C, thus facilitating an autoimmune response to the protein and precipitating an antibody- and cell-mediated hyperimmune reaction in the peripheral cornea.

[Mooren's ulcer]

The article reviews available data on Mooren's ulcer - a rare disease of, supposedly, autoimmune origin that manifests as peripheral ulceration of the cornea and poses a risk of its perforation. The variability of clinical presentation and course of the disease often leads to misdiagnosis and inadequate treatment. The present review focuses on specific signs characteristic of the disease and the most effective methods of its treatment.

Case of bilateral Mooren's ulcers following filtering surgery using EX-PRESS glaucoma filtering devices

Purpose

To report our findings in a case of bilateral Mooren's ulcer that developed after filtering surgeries using the EX-PRESS glaucoma filtering device (EX-PRESS surgery).

Patients and methods

A 71-year-old Japanese man with primary open angle glaucoma underwent EX-PRESS surgery first in his left eye and 1 month later in his right eye. He developed Mooren's ulcer in his right eye at 7 months and in his left eye at 10 months after the initial EX-PRESS surgery. Systemic examinations showed no collagen vascular disease, and he did not have a history of bacterial or viral infections. He was not allergic to metallic materials. Before the EX-PRESS surgery, he had underdone cataract surgery combined with trabeculotomy in both eyes, and a reoperation of trabeculotomy in his left eye. He had not developed Mooren's ulcer after these surgeries. The Mooren's ulcer after the EX-PRESS surgery was treated with oral prednisolone (30 mg tapering) in combination with topical 0.1% betamethasone sodium. The ulcers were responsive and healed well in three months.

Conclusions

The EX-PRESS devices were most likely the cause of the Mooren's ulcers considering that they were located close to the site of EX-PRESS insertion and no peripheral corneal ulcer developed after prior intraocular surgeries.

Should Patients with Hidradenitis Suppurativa Undergo LASIK?

Hidradenitis suppurativa (HS) is a relatively common chronic inflammatory disease with immune dysregulation. While eye manifestations of HS are rare, a dilemma arises when these patients seek treatment for refractive errors. Although excimer laser surgery can be safely performed in patients with autoimmune and immune-mediated inflammatory disease, there are caveats. Aside from the routine laser-assisted in situ keratomileusis (LASIK) screening tests, in some instances, we recommend additional screening tests in patients with HS, such as dry eye tests, consultation with specialists regarding HS diagnosis and treatment, careful assessment of the eyelids and periorbital structures, and thorough history of past and current lesions and treatments. After these patients undergo LASIK, careful, frequent, and long-term follow-up is necessary. Any adverse event or complication should be managed immediately. FUNDING: Research to Prevent Blindness funded the study. Hoopes Vision funded the Rapid Service Fees.

HCV Extrahepatic Manifestations

Hepatitis C virus (HCV) has been shown to affect many tissues other than liver. However, of the many extrahepatic manifestations (EMs) that have been associated with HCV, including cryoglobulinemia, lymphoma, insulin resistance, type 2 diabetes and neurological disorders, only a few have been shown to be directly related to HCV infection of extrahepatic tissues. HCV-triggered immune-mediated mechanisms account for most of the EMs. It is estimated that up to 74% of patients with chronic hepatitis C can develop at least one EM. All HCV patients with EMs should be considered for antiviral therapy, although not all will resolve with sustained virological response.

Case report: bilateral Mooren ulcer in association with hepatitis C

BACKGROUND

Mooren ulcer has been considered as an idiopathic autoimmune keratitis. However, it has been in some cases suggested to be associated with hepatitis C, although the evidence is very vague.

CASE PRESENTATION

We present a case of a man who was diagnosed with a primary Mooren ulcer in his right eye. The eye became blind despite of intensive treatment with local medications and extensive surgical procedures. After 10 years, the patient was diagnosed with the same disease, now in his left, previously healthy eye. There was no history that would suggest a secondary Mooren ulcer, but a chronic hepatitis C infection was detected. Treatment was targeted against hepatitis C (ribavirin and interferon) in addition to immunosuppressive medical and surgical treatment which resulted in a full and more than 6 years lasting remission of the disease.

CONCLUSIONS

Whether the immunomodulatory and immunosuppressive medication against hepatitis C was the key reason for the good results in the treatment of the second eye, remains elusive. The causality of hepatitis C with respect to the pathogenesis of Mooren ulcer on this patient remains open, but should be considered as one of the possible etiological factors of the disease.

A Case of Peripheral Ulcerative Keratitis Associated with Autoimmune Hepatitis

Purpose

To describe a case of peripheral ulcerative keratitis in the setting of autoimmune hepatitis and possible overlap syndrome with primary sclerosing cholangitis.

Case Report

A 48-year-old African American female with autoimmune hepatitis with possible overlap syndrome with primary sclerosing cholangitis presented with tearing, irritation, and injection of the left eye that was determined to be peripheral ulcerative keratitis. The patient was treated with topical and systemic steroids, immunosuppressant drugs (azathioprine and mycophenolate mofetil), a biologic (rituximab), and surgery (conjunctival resection), and the peripheral ulcerative keratitis epithelialized but ultimately led to corneal perforation.

Conclusion

In this unique case, a patient with peripheral ulcerative keratitis who underwent treatment ultimately had a corneal perforation. This case may suggest a possible relationship between autoimmune hepatitis and peripheral ulcerative keratitis.

Peripheral Ulcerative Keratitis Secondary to Chronic Hepatitis B Infection

PURPOSE

To report a unique case of peripheral ulcerative keratitis secondary to hepatitis B virus (HBV)-associated cryoglobulinemia and vasculitis and its pharmacological and surgical treatment and 2-year follow-up.

METHODS

A 52-year-old woman presented with unilateral eye pain and photophobia, arthralgia, remnants of a maculopapular rash, and subsequently facial numbness several weeks later. Her best spectacle-corrected visual acuity (BSCVA) in the affected eye was 20/80. Slit-lamp examination revealed severe superior corneal thinning without infiltrate. Corneal ulceration worsened until 10% of the cornea remained. Laboratory workup was positive for rheumatoid factor and revealed significantly decreased C4 complement, and HBV serology was positive.

RESULTS

Clinical history, examinations, and laboratory results suggest HBV-associated cryoglobulinemia and vasculitis. Management included prednisone, cyclophosphamide, and mycophenolate mofetil for immunosuppression and tenofovir for HBV treatment. Conjunctival resection and a glue patch were used to reduce inflammation and stabilize corneal melt. BSCVA improved after treatment was initiated. Two years after initial presentation, her BSCVA is 20/30, significantly improved from her vision at presentation.

CONCLUSIONS

Diagnosis of peripheral ulcerative keratitis requires thorough history and physical examinations given the numerous causes. Prompt treatment including immunosuppressive medication and, in this case, antiviral medication is crucial to preventing serious visual consequences including corneal perforation and blindness.

International diagnostic guidelines for patients with HCV-related extrahepatic manifestations. A multidisciplinary expert statement

Hepatitis C virus (HCV) infection is responsible for both hepatic and extra-hepatic disorders (HCV-EHDs); these latter are correlated on one hand clearly with HCV lymphotropism causing immune-system dysregulation as well as with viral oncogenic potential, and on the other hand probably with chronic inflammatory status causing cardio-metabolic complications as well as neurocognitive disturbances. The spectrum of HCV-EHDs ranges from mild or moderate manifestations, such as arthralgia, sicca syndrome, peripheral neuropathy, to severe, life-threatening complications, mainly vasculitis and neoplastic conditions. Given the clinical heterogeneity of HCV-EHDs, HCV-infected individuals are inevitably referred to different specialists according to the presenting/prevalent symptom(s); therefore, the availability of comprehensive diagnostic guidelines is necessary for a patient's whole assessment that is decisive for early diagnosis and correct therapeutic approach of various hepatic and HCV-EHDs, regardless of the specific competencies of different physicians or referral centers. In this respect, a multidisciplinary network of experts, the International Study Group of Extrahepatic Manifestations Related to Hepatitis C Virus Infection (ISG-EHCV), was organized with the intention to formulate diagnostic guidelines for the work-up of possible HCV-EHDs. There was a broad consensus among ISG-EHCV members on the proposed guidelines, which essentially are based on two main levels of patient's assessment. At the referral stage, it is proposed that all patients with HCV infection should be invariably examined by means of first-line diagnostic procedures including virological and hepatic parameter evaluation, as well as the detection of clinical findings that may suggest one or more HCV-EHDs. This preliminary assessment should reveal specific HCV-EHDs, which will be deeper analyzed by means of second-line, targeted investigations. The proposed multidisciplinary expert statement represents the first attempt to draw comprehensive diagnostic guidelines for HCV-infected individuals encompassing the entire spectrum of HCV-related disorders, namely typical hepatic manifestations along with less common, often unpredictable HCV-EHDs. The HCV-EHDs may compromise to a substantial degree the overall disease outcome in a significant number of HCV-infected individuals that renders their timely identification and treatment an imperative. In conclusion, the application of standardized but thorough diagnostic guidelines of HCV-EHDs is advisable at the referral stage as well as during the follow-up period of HCV infected patients. It is envisioned that the proposed strategy will result in improvement of clinical outcomes in such patients.

Extrahepatic morbidity and mortality of chronic hepatitis C

Chronic hepatitis C virus (HCV) infection is associated with several extrahepatic manifestations. Patients with HCV may develop mixed cryoglobulinemia and its sequelae, ranging from cutaneous and visceral vasculitis to glomerulonephritis and B-cell non-Hodgkin lymphoma. HCV-infected patients have increased rates of insulin resistance, diabetes, and atherosclerosis, which may lead to increased cardiovascular morbidity and mortality. Neurological manifestations of HCV infection include fatigue and cognitive impairment. The mechanisms causing the extrahepatic effects of HCV infection are likely multifactorial and may include endocrine effects, HCV replication in extrahepatic cells, or a heightened immune reaction with systemic effects. Successful eradication of HCV with interferon alfa and ribavirin was shown to improve some of these extrahepatic effects; sustained virological response is associated with resolution of complications of cryoglobulinemia, reduced levels of insulin resistance, reduced incidence of diabetes and stroke, and improved fatigue and cognitive functioning. The availability of new interferon-free, well-tolerated anti-HCV treatment regimens is broadening the spectrum of patients available for therapy, including those in whom interferon was contraindicated, and will likely result in greater improvements in the extrahepatic manifestations of HCV. If these regimens are shown to confer significant benefit in the metabolic, cardiovascular, or neuropsychiatric conditions associated with HCV infection, extrahepatic manifestations of HCV may become a major indication for treatment even in the absence of liver disease.

Ocular surface and tear parameters in patients with chronic hepatitis C at initial stages of hepatic fibrosis

PURPOSE

The aim of this study was to evaluate changes in ocular surface and tear function parameters in chronic hepatitis C at initial stages of hepatic fibrosis.

METHODS

Thirty-one patients with biopsy-proven chronic hepatitis C and 31 age- and sex-matched healthy control subjects without systemic hepatitis C infection were examined with the Ocular Surface Disease Index (OSDI) questionnaire, Schirmer I, tear film break-up time, and scoring of ocular surface fluorescein and Rose Bengal staining using modified Oxford and van Bijsterveld scoring systems, respectively.

RESULTS

All ocular surface parameters, except OSDI and corneal staining scores, were significantly worse in hepatitis C group. The control group had greater OSDI scores than the hepatitis C group, but there was no statistically important difference. In subgroup analysis, progression of hepatic fibrosis was found to be correlated strongly with decreased Schirmer test I, increased OSDI, lid parallel conjunctival folds, conjunctival, and corneal staining scores.

CONCLUSION

Patients with chronic hepatitis C were more likely to exhibit severe ocular surface damage and signs of dry eye.

Interventions for Mooren's ulcer

BACKGROUND

Mooren's ulcer is a chronic, painful peripheral ulcer of the cornea. Its cause is unknown but it can or will lead to loss of vision if untreated. Severe pain is common in patients with Mooren's ulcer and the eye(s) may be intensely reddened, inflamed and photophobic, with tearing. The disease is rare in the northern hemisphere but more common in southern and central Africa, China and the Indian subcontinent. There are a number of treatments used such as anti-inflammatory drugs (steroidal and non-steroidal), cytotoxic drugs (topical and systemic), conjunctivectomy and cornea debridement (superficial keratectomy). There is no evidence to show which is the most effective amongst these treatment modalities.

OBJECTIVES

The aim of this systematic review is to assess the effectiveness of the various interventions (medical and surgical) for Mooren's ulcer.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 5), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to June 2013), EMBASE (January 1980 to June 2013), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to June 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 4 June 2013.

SELECTION CRITERIA

We planned to include randomised controlled trials (RCTs) or discuss any prospective non-RCTs in the absence of any RCTs. The trials included would be of people of any age or gender diagnosed with Mooren's ulcer and all interventions (medical and surgical) would be considered.

DATA COLLECTION AND ANALYSIS

Two authors screened the search results independently; we found no studies that met our inclusion criteria.

MAIN RESULTS

As we found no studies that met our inclusion criteria, we highlighted important considerations for conducting RCTs in the future in this area.

AUTHORS' CONCLUSIONS

We found no evidence in the form of RCTs to assess the treatment effect for the various interventions for Mooren's ulcer. High quality RCTs that compare medical or surgical interventions across different demographics are needed. Such studies should make use of various outcome measures, (i.e. healed versus not healed, percentage of area healed, speed of healing etc.) as well as ensuring high quality randomisation and data analysis, as highlighted in this review .

Interventions for Mooren's ulcer

BACKGROUND

Mooren's ulcer is a chronic, painful peripheral ulcer of the cornea. Its cause is unknown but it can or will lead to loss of vision if untreated. Severe pain is common in patients with Mooren's ulcer and the eye(s) may be intensely reddened, inflamed and photophobic, with tearing. The disease is rare in the northern hemisphere but more common in southern and central Africa, China and the Indian subcontinent. There are a number of treatments used such as anti-inflammatory drugs (steroidal and non-steroidal), cytotoxic drugs (topical and systemic), conjunctivectomy and cornea debridement (superficial keratectomy). There is no evidence to show which is the most effective amongst these treatment modalities.

OBJECTIVES

The aim of this systematic review is to assess the effectiveness of the various interventions (medical and surgical) for Mooren's ulcer.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 4), MEDLINE (January 1950 to April 2011), EMBASE (January 1980 to April 2011), Latin American and Caribbean Health Sciences Literature Database (LILACS), (January 1982 to April 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and ClinicalTrials.gov (www.clinicaltrial.gov). There were no language or date restrictions in the search for trials. The electronic databases were last searched on 16 April 2011.

SELECTION CRITERIA

We planned to include randomised controlled trials (RCTs) or discuss any prospective non-RCTs in the absence of any RCTs. The trials included would be of people of any age or gender diagnosed with Mooren's ulcer and all interventions (medical and surgical) would be considered.

DATA COLLECTION AND ANALYSIS

Two authors screened the search results independently; we found no studies that met our inclusion criteria.

MAIN RESULTS

As we found no studies that met our inclusion criteria, we highlighted important considerations for conducting RCTs in the future in this area.

AUTHORS' CONCLUSIONS

We found no evidence in the form of RCTs to assess the treatment effect for the various interventions for Mooren's ulcer. High quality RCTs that compare medical or surgical interventions across different demographics are needed. Such studies should make use of various outcome measures, (i.e. healed versus not healed, percentage of area healed, speed of healing etc.) as well as ensuring high quality randomisation and data analysis, as highlighted in this review .

Hepatitis C virus presumably associated bilateral consecutive anterior ischemic optic neuropathy

PURPOSE

To report a case of bilateral nonarteritic anterior ischemic optic neuropathy (NAION) in a hepatitis C (HCV) infected patient and demonstrate the relationship between HCV and the development of NAION.

METHODS

Case report.

RESULTS

A 43-year-old woman with chronic HCV infection and long-term euthyroid autoimmune thyroiditis suddenly lost vision in her right eye, and 6 months later in her left eye, due to NAION. Slightly elevated levels of aminotransferases suggested liver infection activity. Anti-HCV antibody was detected; the genotype of the virus was 1b and the viral RNA level was 1.8 x 106 IU/mL. Liver biopsy proved chronic active hepatitis (Ishak score grading: 7, staging: 2). Except for the elevated levels of antithyroid antibodies and a weak antinuclear factor, the detailed laboratory examinations (thrombophilia, cryoglobulin, anticardiolipin antibodies, co-infections) revealed no other abnormalities; a causative relationship between the underlying chronic hepatitis C and bilateral NAION therefore seems probable. The patient was treated with pegylated interferon and ribavirin for 1 year and a sustained viral remission could be achieved. Her vision has neither improved nor deteriorated further.

CONCLUSIONS

This appears to be the first reported case of bilateral NAION presumably caused by HCV infection.

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

AIM

To investigate the association between chronic hepatitis C virus (HCV) infection and Mooren's ulcer.

METHODS

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.

RESULTS

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.

CONCLUSION

There was no association between chronic HCV infection and Mooren's ulcer in this limited case series study.

[A case report of a recurrence of Mooren's ulcer after cataract surgery]

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.

Treatment of Mooren's ulcer with topical administration of interferon alfa 2a

OBJECTIVE

To report an apparently beneficial effect of topical interferon alfa 2a (IFNalpha2a) as a single therapeutic agent in the treatment of Mooren's ulcer.

DESIGN

Two case reports.

PARTICIPANTS

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.

INTERVENTION

Patients with a clinical diagnosis of Mooren's ulcer were treated with topical IFNalpha2a until their lesions resolved.

MAIN OUTCOME MEASURES

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.

RESULTS

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.

CONCLUSIONS

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.

Vogt-Koyanagi-Harada disease in patients with chronic hepatitis C

PURPOSE

To report the cases of four patients with hepatitis C virus infection who experienced clinical features that are virtually identical to Vogt-Koyanagi-Harada disease (VKH).

DESIGN

Retrospective observational case series.

METHODS

Medical records of patients who were referred between January and December 2003 were reviewed for diagnosis and management of VKH and who also had chronic hepatitis C virus (HCV) infection.

RESULTS

Four white patients had the clinical features of VKH. Three of the patients experienced intraocular inflammation while they were being treated for HCV infection with pegylated interferon alpha 2b and ribavirin. The intraocular inflammation responded to systemic corticosteroid treatment and to discontinuation of antiviral agents.

CONCLUSION

Although the number of patients who were studied is limited, there appears to be an association between HCV infection that was treated with pegylated interferon alpha 2b and the development of VKH-like disease. Further studies are required to confirm such an association.

Cataract surgery in patients with Mooren's ulcer

PURPOSE

To assess the outcome of cataract surgery in patients with Mooren's ulcer.

SETTING

Ocular Immunology and Uveitis Service, L.V. Prasad Eye Institute, Hyderabad, India.

METHODS

In this interventional case series, the medical records of 6 patients with Mooren's ulcer who had cataract surgery were retrospectively reviewed. Five patients had uneventful extracapsular cataract extraction with intraocular lens (IOL) implantation, and 1 patient had phacoemulsification with IOL implantation. The visual acuity and postoperative course of the patients were reviewed. The patients were followed to detect, and if present treat, a recurrence of Mooren's ulcer.

RESULTS

The follow-up ranged from 3 months to 2 years. The preoperative visual acuity ranged from 20/60 to hand movements. Postoperatively, the best corrected visual acuity improved to 20/20 to counting fingers close to face. Mooren's ulcer recurred 8 months after surgery in 1 patient and was treated appropriately.

CONCLUSIONS

Results indicate that cataract surgery can be safe in patients with Mooren's ulcer and visually significant cataract. Performing surgery in a quiet, noninflamed eye improves the prognosis in these cases.

Hepatitis C virus-associated keratitis

AIM

To study the association between chronic hepatitis C virus (HCV) and Mooren's type keratitis.

METHOD

A total of 50 patients with chronic HCV were screened for any evidence of corneal ulceration. Detailed ocular examination was conducted by slit-lamp biomicroscopy. Patients with history of trauma to the eye or previous herpetic keratitis were excluded from the study.

RESULTS

There were 37 males and 13 females. The age of the patients ranged from 10 to 70 years. There was no evidence of Mooren's ulcer in any of our patients.

CONCLUSION

No association between chronic HCV and Mooren's ulcer was found in our study. Screening therefore in such cases is not necessary.

The eye in gastrointestinal disease

This article reviews disorders in which both gastrointestinal and ocular disease can occur. Gastrointestinal disease can affect the eye as part of the disease spectrum, and in other instances both the gastrointestinal system and the eye may be involved as part of a systemic disease process. The gastrointestinal system may be adversely affected by the treatment of an unrelated eye disease. Also, certain infections of the gastrointestinal system can have an adverse effect on the eye.

[Severe Moorens ulcer: efficacy of monthly cyclophosphamide intravenous pulse treatment]

PURPOSE

Mooren's ulcer (MU) is a chronic peripheral corneal ulceration featuring conjunctival immunoglobulin deposits. It is considered as the result of a limbic immune process with hyperactivation of T and B lymphocytes. The etiology remains unknown. The response to topical steroid therapy and surgical procedures usually poor and the visual outcome can be devastating.

METHODS

Clinical follow-up of 3 patients who had rebel MU to conventional therapy, and were treated with 1g monthly intravenous cyclophosphamide.

RESULTS

First patient was a 24-years-old man who had MU in his left eye. The response to surgical procedure and intravenous steroid treatment was poor and corneal perforation occurred. The affected cornea healed after 9 months of Cy treatment. The second patient was a 50-years-old man who had MU in his left eye, which did not improved with lamellar keratoplasty and topical steroid therapy. Corneal healing was obtained after 20 months of Cy treatment. The third patient was a 70-years-old man who presented with a furrowed MU in his right eye which healed with conjunctival resection and 4 months of Cy perfusion. No adverse effects of Cy was noted as opposed to Cy given orally.

CONCLUSION

We report the effectiveness of 1g monthly intravenous cyclophosphamide (Cy) treatment in rebel MU. We suggest that immunosuppressive therapy using IV monthly Cy may be proposed in severe rebel MU.

Ocular manifestations of hepatitis C virus infection

Approximately 3.6 million persons in the United States are infected with the hepatitis C virus (HCV), a condition with both hepatic and extrahepatic sequelae. Although no pathognomonic manifestation of HCV infection in the eye has been demonstrated, associations between HCV infection and various ocular syndromes have been reported in small case series and individual patients. At this time, the ocular manifestations of HCV infections best supported by the literature include a dry eye syndrome similar to Sjögren syndrome, and ischemic retinopathy caused by either an HCV-induced vasculitis or treatment with interferon. Patients with diabetes seem to be more susceptible to interferon retinopathy and to subsequent permanent visual loss. There have been no cases of HCV transmission via corneal transplantation, suggesting that current cadaveric screening protocols are effective in preventing this route of transmission. Screening for HCV should be considered in patients with risk factors for HCV infection who suffer from unexplained ischemic retinopathy or dry eyes.

Prevalence of seropositivity for hepatitis C virus in cataract patients and the general population

PURPOSE

To investigate the epidemiologic relationship between hepatitis C virus (HCV) infection and cataract.

SETTING

Yoshida Eye Clinic, Fukuoka, Japan.

METHODS

This study included 492 patients with age-related cataract and 2624 controls who had a municipal mass health screening. All subjects were 60 years or older and inhabitants of Chikugo City (population 45000), Fukuoka, Japan. Each subject was serologically tested for HCV using the third-generation enzyme immunoassay. Seropositivity was compared in subgroups consisting of patients by decade; that is 60 to 69 years of age, 70 to 79 years of age, and 80 to 90 years of age.

RESULTS

The prevalence of HCV in the cataract group and health-screening (control) group was 18.3% and 7.1%, respectively, in the 60- to -69 year subgroup; 17.8% and 6.6%, respectively, in the 70- to 79-year subgroup; and 15.1% and 3.7%, respectively, in the 80- to 90-year subgroup. In each subgroup, the prevalence of HCV was significantly higher in the cataract group than in the control group (P <.01, chi-square test). In the cataract group, the HCV seropositive and seronegative groups did not differ significantly in the prevalence of hepatitis B virus (P =.548, Fisher exact probability test).

CONCLUSIONS

Patients with age-related cataract had significantly higher seropositivity for HCV than an age-matched general population. This suggests that HCV infection may play a role in the development and/or progression of cataract.

Extrahepatic manifestations of chronic viral hepatitis

Hepatitis B (HBV) and C (HCV) viruses are well-recognized causes for chronic hepatitis, cirrhosis, and even for hepatocellular carcinoma. Apart from liver disease, these viral infections are known to be associated with a spectrum of extrahepatic manifestations. The prevalence of clinically significant extrahepatic manifestations is relatively low, but it can be associated with significant morbidity and even mortality. An awareness and recognition of these manifestations is of paramount importance in facilitating early diagnosis and in offering treatment. However, treatments are not necessarily effective, and patients may continue with disabling extrahepatic manifestations. Hepatitis B virus has been well recognized as causing a variety of manifestations that include skin rash, arthritis, arthralgia, glomerulonephritis, polyarteritis nodosa, and papular acrodermatitis. More recently, infection with hepatitis C virus has elicited considerable interest for its role in a spectrum of extrahepatic manifestations. Among the best-reported are cryoglobulinemia, glomerulonephritis, high titer of autoantibodies, idiopathic thrombocytopenic purpura, lichen planus, Mooren's corneal ulcer, Sjögren's syndrome, porphyria cutanea tarda, and necrotizing cutaneous vasculitis. The precise pathogenesis of these extrahepatic complications has not been determined, although the majority represent the clinical expression of autoimmune phenomena.

Hepatitis C virus infection is not associated with a marked increase in the prevalence of ophthalmic morbidity

BACKGROUND

Chronic infection with the hepatitis C virus has been reported to cause a wide variety of ophthalmic lesions. The incidence and significance of these lesions in an unselected population has not been assessed.

METHODS

We studied a group of unselected patients with chronic hepatitis C and performed a full ophthalmic examination on each. As a control group we studied patients with chronic hepatitis B infection.

RESULTS

In 25 patients with chronic hepatitis C we found no increase in the prevalence of significant ocular disease when compared with a cohort of patients with chronic hepatitis B.

CONCLUSION

Chronic heptatitis C does not cause any marked increase in the incidence of ocular disease.

Histopathological and immunohistochemical study of oral lichen planus-associated HCV infection

Background: In recent years, it has been suggested that oral lichen planus (OLP), a chronic inflammatory keratotic lesion, is related to hepatitis C virus (HCV) infection. Therefore, we evaluated whether the presence or absence of HCV infection caused any histopathological differences in OLP tissues. Methods; The subjects consisted of 31 patients with HCV-related liver disease complicated by OLP (32 OLP lesions) and ten OLP patients without complications due to either HCV infection or liver disease (control). A histopathological evaluation was performed in these patients. In addition, immunostaining was done on nine OLP tissues infected with HCV and on six OLP tissues without HCV infection in order to evaluate lymphocyte subsets (T cells or B cells) infiltrating into topical regions with OLP. Furthermore, the severity of hepatic fibrosis and inflammation was evaluated in liver tissues obtained by liver biopsy from six patients with HCV-related liver disease to evaluate whether there were any relationships between the severity of hepatic fibrosis or inflammation and OLP tissues. Results: There were no significant differences in the histopathological characteristics specific to OLP or in the ratios of T and B cells among infiltrating lymphocytes regardless of the presence or absence of HCV infection. Moreover, there were no certain relationships between the severity of hepatic fibrosis or inflammation and the severity of lymphocytic infiltration in OLP. Conclusions: HCV infection does not appear to influence the histopathological and immunohistochemical features of OLP.

Twenty-five-year panorama of corneal immunology: emerging concepts in the immunopathogenesis of microbial keratitis, peripheral ulcerative keratitis, and corneal transplant rejection

PURPOSE

To describe the most recent advances in our understanding of the cellular and molecular mechanisms involved in the immunopathogenesis of corneal immunoinflammatory disorders including microbial keratitis, peripheral ulcerative keratitis. and allograft rejection.

METHODS

Review of the published peer-reviewed literature that has contributed significantly to our modern understanding of corneal immunology. In addition, the authors have summarized the information in conceptual diagrams that highlight the critical cellular and molecular pathways that lead to corneal immune responses in the two most thoroughly studied corneal immune disorders, herpes simplex keratitis (HSK) and transplant rejection.

RESULTS

In spite of the wide array of molecular and cellular factors that mediate corneal immunity, critical mechanistic facets are shared by the various corneal immunoinflammatory disorders. These include activation and migration of local antigen-presenting cells (APCs), including Langerhans cells (LCs), upregulation in pleiotropic proinflammatory cytokines such as interleukin-1 (IL-1) and tumor necrosis factor-alfa (TNF-alpha) that can mediate a wide array of immune functions in addition to up-regulating protease expression. and chemokines that play a critical role on the one hand in attracting nonantigen-specific inflammatory cells such as neutrophils and on the other in attracting CD4+ T helper type 1 (Th1) cells that mediate most of the destruction in the cornea.

CONCLUSIONS

In the last 25 years, we have seen our field develop from a descriptive stage into a new phase where the fundamental processes that mediate and effect corneal immunity are being accurately deciphered. It is anticipated that this new knowledge will allow development of specific molecular and genetic therapeutic strategies that could target critical steps in the immunopathogenesis of disease without the untoward side-effects of nonspecific generalized immune suppression that still remains the standard of care today.

Prevalence of diabetes mellitus in patients with end-stage liver cirrhosis due to hepatitis C, alcohol, or cholestatic disease

BACKGROUND/AIMS

The aims were to study: 1) the prevalence of diabetes mellitus in patients with end-stage liver cirrhosis due to hepatitis C, alcohol, or cholestatic liver disease, 2) viral and host immunogenetic factors that may predispose to diabetes, and 3) liver transplantation outcome in patients with or without diabetes.

METHODS

Fasting blood glucose values of patients who underwent liver transplantation because of hepatitis C-related cirrhosis (73 patients) were compared with those of patients with cirrhosis due to cholestatic (78 patients) or alcoholic liver disease (53 patients) and to a general population. Data on diabetes prevalence in a population without liver cirrhosis was based on the prevalence of diabetes in Olmsted County, Minnesota, residents. HLA was determined using serologic assays. Hepatitis C virus genotypes were determined with polymerase chain reaction amplification and direct sequencing. Hepatitis G RNA was detected with polymerase chain reaction. Liver transplantation outcome in patients with or without diabetes was determined with rejection, retransplantation, or death at 1 year after transplantation as end points.

RESULTS

Of 64 patients with hepatitis C alone, 16 (25%) had diabetes before transplantation compared with 1 of 78 (1.3%) with cholestatic liver disease (p= 0.0001) and 10 of 53 (19%) with alcoholic liver disease (p=0.36). Nine patients had hepatitis C plus cholestatic liver disease; one of these (11%) had diabetes. The prevalence of diabetes in patients with cholestatic liver cirrhosis was not different from that of the general population. The frequency of hepatitis G virus coinfection, HLA-DR3, or HLA-DR4 in hepatitis C and diabetes was not different from that of hepatitis C alone. The distribution of hepatitis C virus genotype was similar in those with and those without diabetes. Diabetes was not associated with increased risk of rejection, retransplantation, or death at 1 year after transplantation, and had no impact on overall survival after transplantation.

CONCLUSIONS

1) The risk of diabetes is not increased in patients with liver cirrhosis due to cholestatic liver disease but is in patients with liver cirrhosis due to hepatitis C or alcoholic liver disease; 2) cofactors (age, sex, body mass index, hepatitis G virus coinfection, hepatitis C virus genotype, or HLA-DR3/DR4) did not explain the increased risk of diabetes in patients with hepatitis C; 3) diabetes before liver transplantation did not change the outcome at 1 year after transplantation or survival.

Mooren ulcer in South India: serology and clinical risk factors

PURPOSE

To investigate the rate of undiagnosed rheumatologic diseases and hepatitis C infection among patients with the clinical diagnosis of Mooren ulcer seen at Aravind Eye Hospital, Madurai, South India.

METHODS

Twenty-one patients with the clinical diagnosis of Mooren ulcer and 44 control patients underwent a complete ophthalmic history and examination, as well as serologic testing for antinuclear antibodies, rheumatoid factor, antineutrophil cytoplasmic antibodies, herpes simplex virus 1 antibodies, and hepatitis C virus antibodies.

RESULTS

There were no statistically significant differences in the rates of seropositivity for antinuclear antibodies, rheumatoid factor, antineutrophil cytoplasmic antibodies, herpes simplex virus 1 antibodies, and hepatitis C virus antibodies between patients with Mooren ulcer and control patients. Two patients with Mooren ulcer and four control patients were found to have a rheumatoid factor titer of greater than 1:20. One of the control patients, but none of the patients with Mooren ulcer, was found to have serologic evidence of hepatitis C infection. A history of corneal trauma, surgery, or infection was reported by 68% of patients with Mooren ulcer, compared with 20% of control patients (P < .001). Among patients with Mooren ulcer, bilateral disease occurred in 37% of patients, visual acuity was reduced to light perception in 15% of eyes, and perforation occurred in 19% of eyes.

CONCLUSIONS

Nineteen (90%) of 21 patients with the clinical diagnosis of Mooren ulcer were found to have no evidence of an underlying rheumatologic disease by history, examination, or serologic testing, and none was seropositive for hepatitis C. However, patients with Mooren ulcer were more likely than control patients to report a history of corneal trauma, surgery, or infection.

Decreased tear lactoferrin concentration in patients with chronic hepatitis C

BACKGROUND/AIMS

Decreased tear volume in patients with chronic hepatitis C has been reported in the literature. Lactoferrin is abundantly present in human tears, the main source of which is the acini of the lacrimal glands. In this study tear lactoferrin levels were measured to investigate the dry eye condition of patients with chronic hepatitis C.

METHODS

Lactoferrin in tears/fluid was measured by a radial immunodiffusion assay in 42 patients with chronic hepatitis C. The rate of lacrimal secretion was determined by the cotton thread test. Rose bengal staining of the ocular surface was also performed.

RESULTS

Only three patients out of 42 complained of dry eye sensation and, in 31 patients, six showed positive results on the rose bengal staining test of the ocular surface. The lactoferrin concentration of tear fluid in the chronic hepatitis C group (1.42 (SD 0.56) mg/ml) was significantly lower than in the control group (1.90 (0.62) mg/ml; p <0.00048). The cotton thread test results in the chronic hepatitis C group (12.9 (5. 5) mm) were significantly lower than in the control group (17.9 (5. 3) mm; p<0.00048). Also, in the chronic hepatitis C group, tear lactoferrin concentration correlated with the results of the cotton thread test (r = 0.35, p<0.05).

CONCLUSION

Chronic hepatitis C patients showed both decreased tear volume, and decreased tear lactoferrin concentration. These findings suggest that there may be dysfunction of the lacrimal glands in patients with chronic hepatitis C, which may account for the mild dry eye.

Vasculitic peripheral ulcerative keratitis

The onset of peripheral ulcerative keratitis in the course of a connective tissue disorder, such as rheumatoid arthritis, relapsing polychondritis, or systemic lupus erythematosus, may reflect the presence of potentially lethal systemic vasculitis. Moreover, peripheral ulcerative keratitis may be the first sign of systemic necrotizing vasculitis in patients with Wegener's granulomatosis, polyarteritis nodosa, microscopic polyangiitis, or Churg-Strauss syndrome. Although the exact pathogenesis of this severe corneal inflammation and destruction is not well understood, evidence points to a dysfunction in immunoregulation with immune complexes formed in response to autoantigens or to some unknown microbial antigen depositing in scleral and limbal vessels. These events lead to changes that are mainly responsible for the resulting tissue damage. In pauci-immune vasculitides positive for antineutrophil cytoplasmic antibodies, cell-mediated cytotoxicity may play an important role in the pathogenesis of peripheral ulcerative keratitis. Untreated systemic conditions such as those mentioned above may carry a grave prognosis for the eye and may also be life-threatening. Immunosuppressive therapy with corticosteroids and cytotoxic agents is, we believe, mandatory in the treatment of these multisystem disorders associated with vasculitic peripheral ulcerative keratitis.