Clinical characteristics of Mooren's ulcer in South India

Peripheral ulcerative keratitis due to systemic diseases

PURPOSE OF REVIEW

To discuss peripheral ulcerative keratitis, with a focus on the evaluation and management of associated systemic diseases.

RECENT FINDINGS

Peripheral ulcerative keratitis (PUK) is a sight-threatening condition that is often defined by the presence of a crescent-shaped area of peripheral corneal thinning, an epithelial defect, and an inflammatory corneal infiltrate. It is highly associated with rheumatoid arthritis, systemic necrotizing vasculitides like granulomatosis with polyangiitis, and collagen vascular diseases like systemic lupus erythematosus. Undertreated PUK carries a risk of vision loss and premature death.

SUMMARY

Multidisciplinary collaboration between the ophthalmologist, rheumatologist, and other consultants is required. Early and aggressive steroid-sparing therapy should be considered in cases due to noninfectious systemic disease.

Surgical Management of Peripheral Ulcerative Keratitis: Update on Surgical Techniques and Their Outcome

Peripheral ulcerative keratitis (PUK) is an inflammatory, necrotic condition in the peripheral cornea which may end in corneal perforation and visual morbidity if not treated adequately. PUK can occur due to infectious or non-infectious causes. Early cases need medical therapy, both locally and systemically (for some cases). However, advanced PUK may necessitate surgical removal of inciting cause of the pathology and maintaining tectonic stability. Such surgical treatment, including corneal transplantations, may be used in an emergency setting or for visual rehabilitation following preliminary stabilization of the affected cornea. The outcome of these surgeries need to be analyzed to understand the long-term visual prognosis of such eyes. This is an attempt to analyze surgical modalities in the management of PUK and their outcomes.

Etiology, clinical profile, and treatment outcome of peripheral ulcerative keratitis

PURPOSE

To assess the etiology, clinical features, and treatment outcome in patients with peripheral ulcerative keratitis (PUK).

METHODS

In this retrospective, observational study, forty-eight eyes of 32 consecutive patients with PUK were included. Demographic profile, etiology, clinical features, treatment history, and outcome were documented.

RESULTS

Of the 32 patients, 19 (59%) were male and the mean age at presentation was 54.72 ± 14.92 years. Sixty-eight percent of patients were from rural backgrounds. Half of the patients had bilateral involvement. Fifty percent of patients presented after 4 weeks of the onset of symptoms. Of 48 eyes at presentation, 11 had mild disease, 9 had moderate disease and 28 had severe disease. At presentation, best-corrected visual acuity <3/60 was found in 26 (54%) eyes. Mooren's ulcer (40% eyes) was the most common etiology for PUK. Rheumatoid factor was positive in 8 of 32 patients (25%). Of 32 patients, 19 (59%) required systemic immunosuppression for the control of disease activity. Surgical intervention to maintain anatomical integrity was required in 27 (56%) eyes. No significant change in vision was seen in pretreatment and posttreatment groups. Four eyes failed to heal after 4 weeks of initiation of treatment due to noncompliance of the patient. None of our patients died during follow-up.

CONCLUSION

PUK is an indicator of occult systemic autoimmune disease. Mooren's ulcer is the most common cause of PUK. Prompt and adequate immunosuppression is not only eye saving but also lifesaving for patients with PUK of autoimmune origin.

Peripheral Ulcerative Keratitis Secondary to Atypical Hemolytic Uremic Syndrome

PURPOSE

To report a case of peripheral ulcerative keratitis secondary to atypical hemolytic uremic syndrome.

METHODS

We report the case of a 76-year-old man who presented with bilateral aggressive peripheral ulcerative keratitis. Clinical examinations and investigations are reported from the patients' admission.

RESULTS

The patient had an extended workup for autoimmune and infectious etiologies that all returned negative. The laboratory work in conjunction with renal biopsy and clinical symptoms were consistent with atypical hemolytic uremic syndrome. The patient was treated with systemic steroids for his peripheral ulcerative keratitis and underlying systemic disease. Corneal glueing and amniotic membrane grafting was also performed.

CONCLUSIONS

To our knowledge, we report the first known case of peripheral ulcerative keratitis secondary to atypical hemolytic uremic syndrome. In cases where the standard workup is negative, this diagnosis should be considered because it can have significant systemic morbidity.

Treatment of Mooren's ulcer coexisting with a pterygium using an intrastromal lenticule obtained from small-incision lenticule extraction: case report and literature review

The coexistence of Mooren’s ulcer and a pterygium is an extremely rare ocular condition that has been infrequently reported in the literature to date. We herein present the first case of treatment of Mooren’s ulcer coexisting with a pterygium using a lenticule obtained by myopic small-incision lenticule extraction (SMILE). A 61-year-old woman presented with a 3-month history of recurrent ocular pain and red eye caused by Mooren’s ulcer coexisting with a pterygium. She received topical immunosuppressive and anti-infection treatments for almost 3 months. However, her ocular symptoms and signs did not substantially improve. Therefore, we performed lamellar keratoplasty with a corneal lenticule obtained by SMILE, followed by pterygium excision combined with conjunctival autografting. The patient recovered well with no complications or recurrence 1 year postoperatively. Our success suggests that combined surgery may be an effective management for coexistence of Mooren’s ulcer and a pterygium if conservative treatments fail. A corneal lenticule obtained by SMILE can be used as the lamellar keratoplasty graft in such patients.

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.

A proteomic approach towards understanding the pathogenesis of Mooren's ulcer

Mooren's ulcer (MU) is a refractory autoimmune corneal ulcer with a high recurrence rate. So far, its molecular profiles and pathomechanisms remain largely unknown. Therefore, we aim to characterize the protein profiles of MU specimens by data-independent-acquisition (DIA) mass spectrometry (MS), and to define the functions of differentially-expressed proteins (DEPs). Through LC-MS/MS, 550 DEPs were identified between MU biopsies and age-matched controls (Ctrl). KEGG analysis revealed that the significantly enriched pathways of the up-regulated proteins mainly covered lysosomes, antigen processing and presentation, and phagosomes. We subsequently validated the expressions of the selected candidates using parallel-reaction-monitoring (PRM)-based MS and immunohistochemistry (IHC), including cathepsins, TIMP3, MMP-10, MYOC, PIGR, CD74, CAT, SOD2, and SOD3. Moreover, immunoglobulin (Ig) components and B lymphocytes associated proteins MZB1, HSPA5, and LAP3 in MU were significantly increased and validated by PRM-based MS and IHC. The remarkable enrichment of neutrophil extracellular traps (NETs) components in MU samples was also identified and determined. The up-regulated Ig components and NETs components suggested that B lymphocytes and neutrophils participated in the immunopathology of MU. Importantly, we also identified and validated much more expression of peptidyl arginine deiminase 4 (PADI4) in MU samples. The double-immunofluorescence staining showed the co-localization of citrulline residues with MPO, NE, and IgG in MU samples. These results indicated the presences of PADI4-mediated citrullination modification and anti-citrullinated protein antibodies (ACPAs) in MU samples. Our findings, for the first time, provide a global proteomic signature of MU, which may open a new avenue towards disease pathology and therapeutics.

Bilateral Boston keratoprosthesis type 1 in a case of severe Mooren's ulcer

INTRODUCTION

Mooren's ulcer is a painful, inflammatory chronic keratitis that affects corneal periphery, progressing centripetally, ultimately ending in perforation. The first line of treatment includes systemic immunomodulators, with surgery being the last option. We present a case of bilateral Boston keratoprosthesis implantation for severe Mooren's ulcer that responded differently in each eye.

CLINICAL CASE

A 32-year-old male with corneal opacification, anterior staphylomas, vision of hand movement, was started on systemic immunosuppression with cyclosporine. After two failed penetrating keratoplasties in each eye, high intraocular pressure despite diode cyclophotocoagulation, and cystic macular edema, we performed Boston keratoprosthesis type 1 in both eyes. The right eye responded initially well, with a best-corrected visual acuity of 20/80 and normal intraocular pressure. The left eye presented high intraocular pressure, which required cyclophotocoagulation, ultimately resulting in hypotony. Boston keratoprosthesis was performed but had peripheral corneal necrosis that progressed despite amniotic membrane transplantation and aggressive intensive treatment with medroxyprogesterone, autologous platelet-rich-in-growth-factors eye drops, and oral doxycycline. Thus, replacement of the semi-exposed Boston keratoprosthesis with tectonic penetrating keratoplasty was necessary. However, both eyes developed phthisis bulbi with final visual acuity of perception of light with poor localization.

CONCLUSION

Mainstay treatment of Mooren's ulcer is systemic immunomodulation. Surgical treatment must be considered only when risk of perforation, preferably with inflammation under control. Penetrating keratoplasty frequently fails, and Boston keratoprosthesis may be a viable option. However, postoperative complications, especially uncontrolled high intraocular pressure, corneal necrosis, and recurrence of Mooren's ulcer may jeopardize the outcomes and need to be addressed promptly with intensive topical and systemic treatment.

Peripheral ulcerative keratitis with corneal melt as the primary presentation in a case of human immunodeficiency virus

Peripheral ulcerative keratitis (PUK) is an aggressive, potentially sight-threatening cause for peripheral corneal thinning. It is thought to be the result of immune complex deposition at the limbus, resulting in corneal inflammation and stromal melt. We present a case of a 43-year-old female patient of African origin, presenting with PUK and associated corneal perforation as the primary presentation of HIV infection. An urgent tectonic deep anterior lamellar keratoplasty was performed under general anaesthesia with excellent outcome. The patient was referred to the sexual health clinic and anti-retroviral treatment was initiated. This case is to the best of our knowledge the first report from the UK of PUK with corneal perforation as the primary presentation of HIV infection. As highlighted in this report, infection with HIV may initially be silent; therefore, it is vital to consider HIV infection when dealing with PUK of unknown aetiology.

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.

Clinical Characteristics and Risk Factors of Recurrent Mooren's Ulcer

Purpose

To investigate the clinical characteristics of Mooren's ulcer in East China and to identify the potential risk factors that affect the recurrence of Mooren's ulcer.

Methods

We reviewed the medical records of 95 patients (100 eyes) diagnosed with Mooren's ulcer from May 2005 to December 2014. The patients were classified into recurrent and nonrecurrent groups and followed up for 18 months. The difference between two groups was estimated. The patients in the recurrent group were subdivided according to the history of corneal infection and corneal perforation, respectively. The recurrent time in the subgroups was analyzed.

Results

Patients in the recurrent group were more likely to have a history of corneal infection and corneal perforation than that in the nonrecurrent groups. In patients with recurrent Mooren's ulcer, the median time to first recurrence was 130 days in the infection group, 480 days in noninfection group, and 195 days in the perforation group versus 480 days in nonperforation group.

Conclusion

Corneal infection and corneal perforation were associated with early recurrence of Mooren's ulcer. The tailored follow-up schedule should be used for patients with corneal infection and corneal perforation due to the high risk of recurrence.

Rapid deterioration of Mooren's ulcers after conjunctival flap: a review of 2 cases

Background

Conjunctival flaps are a widely used treatment for numerous corneal ulcers that are caused by microorganismal infections. However, whether it can be performed on immune-mediated corneal ulcers is controversial.

Case presentation

We present two cases of Mooren’s ulcer that were treated using conjunctival flap in an attempt to prevent further corneal perforation at their local hospital. A rapid acceleration in ulcer progression was observed after a conjunctival flap was applied. Ultimately, the two patients underwent corneal transplantation, which required the postoperative use of topical immunosuppressants and resulted in a final cure. In the current report, we also discussed this incorrect surgical choice via a review of conventional interventions that are used to treat Mooren’s ulcer.

Conclusions

These two cases demonstrate that keratoplasty combined with topical immunosuppressants is effective in treating Mooren’s ulcer. Application of conjunctival flaps or autografting could promote progression of ulceration in Mooren’s ulcers.

Mooren Ulcer in a Child Wearing Orthokeratology Contact Lenses

PURPOSE

To report a case of Mooren ulcer that developed in a pediatric patient wearing orthokeratology overnight contact lenses.

METHODS

Case report.

RESULTS

A 10-year-old boy was referred to our clinic because of progressive peripheral corneal ulcer in the right eye, despite the intensive use of fortified antibiotic eye drops. The patient had been using overnight orthokeratology lenses for 4 months before presentation of corneal ulcer. There was no other history of ocular or systemic trauma and disorders. Microbiological tests of the lesion were negative. Systemic evaluation showed no sign of rheumatologic disease. Under a diagnosis of Mooren ulcer, the patient was treated with topical and systemic corticosteroids. After four weeks of treatment, the patient's symptoms rapidly disappeared, and corneal ulcer was healed. The vision recovered to normal with the correction of with-the-rule astigmatism.

CONCLUSIONS

Mooren ulcer can develop in pediatric patients wearing orthokeratology contact lenses. Given rapid progression of Mooren ulcer in a young population, early diagnosis and proper treatment are essential to prevent a devastating outcome.

Mooren's ulcer: 30 years of follow-up

CASE REPORT

A 33-year-old Caucasian female presented with epiphora, ocular pain, and foreign body sensation in both eyes for one month. Examination revealed bilateral peripheral corneal ulcers. The patient had been treated with immunomodulators, and she was treated in the left eye with peripheral semi-circular keratoplasty, penetrating keratoplasty, conjunctival-corneal-scleroplasty, buccal mucosal graft, tibial osteo-keratoprosthesis and finally, retinal detachment.

DISCUSSION

Mooren's ulcer is an immunological corneal disease. This lesion must be treated initially with immunomodulators. Surgical treatment should be considered when a risk of corneal perforation is present, when the perforation appears, or under acute necrosis.

Demographic profile, clinical features and outcome of peripheral ulcerative keratitis: a prospective study

PURPOSE

To evaluate aetiology, demographic profile, clinical features and outcomes in cases of peripheral ulcerative keratitis (PUK).

METHODS

Seventy-six eyes of 65 consecutive patients with PUK were evaluated in this prospective interventional study over an 18 month period, which were followed for 3 years. The main outcome measures were sociodemographic profile, aetiology, clinical features, management strategies and outcome.

RESULTS

Sixty per cent (39/65) of cases were men and mean age was 45.5 ± 17.9 years. Two-thirds (43/65) of the patients were from rural areas with majority (48/65) belonging to low socioeconomic status. Unilateral disease was present in 83% of patients (54/65) with nasal involvement in 60.5% (46/76) cases. The most common aetiology was Mooren's ulcer (31.5% cases (24/76 eyes)) followed by infection and systemic collagen vascular disease. Meibomian gland dysfunction (17/76: 22.3%) was the most common extraocular association and complicated cataract (12/76:15.7%) was the most common intraocular abnormality. In mild and moderate cases, no significant visual improvement was observed (p = 0.085 and p = 0.156) as compared with the pretreatment status. Surgical treatment was successful in maintaining anatomical integrity in 83.3% (30/36) eyes. Recurrence of the disease was seen in one eye in moderate disease and three eyes in severe disease.

CONCLUSIONS

Mooren's ulcer followed by collagen vascular diseases and infection are important causes of PUK in developing countries. Surgical intervention in perforated cases had good anatomical success and visual prognosis.

Mooren's Ulcer in a Cornea Referral Practice in Korea

PURPOSE

To investigate the clinical characteristics of patients with Mooren's ulcer in the Korean population, and to identify the risk factors that affect the therapeutic outcome.

METHODS

We reviewed the medical records of 33 eyes of 24 Korean patients who were referred to a cornea clinic and clinically diagnosed with Mooren's ulcer.

RESULTS

Despite intensive immunosuppression, corneal perforation occurred in 16 of 24 (66.7%) patients, which required tectonic graft. Age was significantly correlated with corneal perforation development: the age was 52.5 ± 21.8 years in patients with perforation and 70.2 ± 6.1 years in those without perforation (p = 0.036). Also, all 8 patients who were 55 years and younger had corneal perforation, while 8 of 16 patients older than 55 years developed perforation (p = 0.022). Other factors had no significant correlation with the occurrence of perforation.

CONCLUSIONS

Young patients with Mooren's ulcer should be treated and carefully followed for high possibility of corneal perforation.

Age distribution of various corneal diseases in China by histopathological examination of 3112 surgical specimens

PURPOSE

To analyze the age distribution of corneal disease in China by histopathological examination.

METHODS

A retrospective histopathological analysis of the prevalence and age distribution of corneal disease was performed on corneal specimens from 3112 patients who underwent corneal surgery between 2001 and 2012 in the Henan Eye Institute.

RESULTS

Infectious keratitis (2212 specimens, 71.08%) was the most common corneal disease. The distribution of age groups was significantly higher after age 30 (16.29%), reaching a peak by age 40 (22.04%) and remaining high until age 59 (21.05%, P < 0.01). The highest age-specific percentage of corneal infection was between the ages of 50 and 59 (83.21%, P < 0.01). Noninfectious corneal diseases occurred mainly in the age range of 10 to 19 years (42.47%) and 20 to 29 years (40.78%). Between the ages of 10 and 19, the leading pathologic diagnosis was keratoconus, accounting for 21.29% of cases. In patients aged 80 and older, the most common noninfectious corneal diseases were Terrien-marginal degeneration (8.33%) and Mooren's ulcer (4.17%). The highest incidence of corneal tumor was seen between the ages of 0 and 9 years (65.83%) and age 80 and older (45.86%; P < 0.01).

CONCLUSIONS

The age distribution of corneal diseases in the Chinese population is distinct from other countries. The corneal diseases tend to increase in prevalence in middle age, especially for infectious corneal disease. The prevalence of corneal tumor is high in early and late life. Corneal degenerative disease occurs predominately in seniors.

Mooren'S ulcer in ibadan, southwest Nigeria

BACKGROUND

Mooren's ulcer has been described as an idiopathic, painful, relentless, peripheral, chronic ulcerative keratitis that progresses circumferentially and centrally, with an unusual geographical presentation and distribution.

AIM

To review the demographic and clinical characteristics of patients with Mooren's ulcer at University College Hospital, Ibadan, Nigeria over seven years, and, the outcome of treatment.

STUDY DESIGN

A retrospective case series.

METHODS

Medical records of all patients with Mooren's ulcer seen in the Eye Clinic, University College Hospital, Ibadan, South-west Nigeria between January 2007 and December 2013 were reviewed.

RESULTS

Thirty-one eyes of 23 patients, (18 males, overall mean age of all patients 30.9 ±16.6 years) were affected with Mooren's ulcer. The right eye was involved in nine (39.1%) patients while eight (34.8%) patients had bilateral lesions. Most common presenting symptoms were redness and pain, with an average of 6.8 clock hour-limbal involvement. All patients received topical and systemic steroids, while eight patients with severe disease, or poor response to treatment with steroids, received systemic methotrexate or cyclophosphamide. Surgical treatment with conjunctivectomy and cryotherapy was undertaken in 14 (60.9%) patients (21 eyes) who had a minimum follow-up period of eight weeks, while those presenting with perforation also had scleral patch graft or direct repair. The ulcer healed with varying degrees of corneal opacity in 18 (85.7%) of the 21 eyes, while the remaining three eyes developed descemetocele, anterior staphyloma or corneal perforation. Large proportion (76.2%) of eyes maintained their presenting acuity.

CONCLUSION

Mooren's ulcer remains an uncommon disease in Ibadan, South-west Nigeria, and the clinical presentation is as recorded in other parts of the West African sub-region. Systemic immunosuppression with methotrexate and scleral patch graft appear to give good outcome in patients presenting with severe ulceration and/or perforation.

Update on peripheral ulcerative keratitis

Ulcerative inflammation of the cornea occurs in the perilimbal cornea, and is associated with autoimmune collagen vascular and arthritic diseases. Rheumatoid arthritis is the most frequent underlying disease. The tendency for peripheral location is due to the distinct morphologic and immunologic characteristics of the limbal conjunctiva, which provides access for circulating immune complexes to the peripheral cornea via the capillary network. Deposition of immune complexes in the terminal ends of limbal vessels initiates immune-mediated vasculitis, and causes inflammatory cell and protein leakage due to vessel wall damage. Development of peripheral ulcerative keratitis associated with systemic disease may represent worsening of a potentially life-threatening disease. Accompanying scleritis, particularly the necrotizing form, is usually observed in severe cases, which may result in corneal perforation and loss of vision. Although first-line treatment with systemic corticosteroids is indicated for acute phases, immunosuppressive and cytotoxic agents are required for treatment of peripheral ulcerative keratitis associated with multisystem disorders. Recently, infliximab, a chimeric antibody against proinflammatory cytokine tumor necrosis factor-alpha, was reported to be effective in cases refractory to conventional immunomodulatory therapy. The potential side effects of these therapies require close follow-up and regular laboratory surveillance.

Emerging role of antioxidants in the protection of uveitis complications

Current understanding of the role of oxidative stress in ocular inflammatory diseases indicates that antioxidant therapy may be important to optimize the treatment. Recently investigated antioxidant therapies for ocular inflammatory diseases include various vitamins, plant products and reactive oxygen species scavengers. Oxidative stress plays a causative role in both non-infectious and infectious uveitis complications, and novel strategies to diminish tissue damage and dysfunction with antioxidant therapy may ameliorate visual complications. Preclinical studies with experimental animals and cultured cells demonstrate significant anti-inflammatory effects of a number of promising antioxidant agents. Many of these antioxidants are under clinical trial for various inflammatory diseases other than uveitis such as cardiovascular, rheumatoid arthritis and cancer. Well planned interventional clinical studies in the field of ocular inflammation will be necessary to sufficiently investigate the potential medical benefits of antioxidant therapies for uveitis. This review summarizes the recent investigations of novel antioxidant agents for ocular inflammation, with selected studies focused on uveitis.

Mooren''s ulcer following extracapsular cataract extraction

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.