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Pui Yi Boey1, Seng-Ei Ti1, Donald TH Tan1,2
1Singapore Eye Research Institute, Singapore National Eye Centre2Dept of Ophthalmology, Yong Loo Lin School of Medicine, National
University of Singapore (NUS), Singapore
The authors have no financial interest in the subject matter of this e-poster.
Singapore Eye Research InstituteSingapore National Eye Centre
Introduction The management of Mooren’s ulcer is difficult due to its
progressive and relapsing nature. The goal of therapy is directed at controlling inflammation
and preserving globe integrity. A stepwise approach in its management has been
suggested, which includes topical steroids, conjunctival resection, systemic immunosuppression and lastly, surgery.1
There is no consensus on the role of surgery Some authors reserve surgical intervention for end-stage disease Others advocate the use of different surgical procedures to
preserve tectonic integrity of the globe, as well as for therapeutic reasons, by removing corneal antigenic targets in the hope of arresting the inflammatory process.2-4
Purpose
To review the surgical management, visual outcome and complications of management of advanced Mooren’s ulceration in Asian eyes in a tertiary eye centre.
Methods Retrospective case notes review of patients requiring surgery
for advanced Mooren’s ulceration from 1992 to 2009 The following data were collected
Indications and type of surgical procedure Conjunctival resection Lamellar keratoplasty (LK) Penetrating keratoplasty (PK) Sclerokeratoplasty (SKP)
Concurrent medical treatment Recurrence of disease
Outcome was assessed in terms of globe integrity and visual acuity at last follow-up
Visual outcome was defined as Good: Best-corrected visual acuity (BCVA) improved or maintained
within 3 Snellen lines Fair: Loss of BCVA by 3 Snellen lines with maintained globe integrity Poor: Loss of vision or globe integrity
Results 26 eyes of 20 patients were included
12 females, 8 males Mean age 59.1 (SD 16.4) years (range 31-90) Mean follow-up time 63.7 (+/- 47.7) months Preoperatively, topical or systemic
immunosuppression was administered in 18 eyes (69.2%)
Indications for surgery at presentation Number of eyes
Impending globe perforation or perforated globe 9
Progressive peripheral corneal ulceration with failure of maximal conservative treatment
17
Surgical procedures Number of eyes
Conjunctival recession/resection 16
Tectonic/therapeutic keratoplasty○Semilunar LK○Central LK○PK○SKP
22257
Final outcome
Patient Age/ Gender
Procedure Reason VA (Initial)
VA (Final)
No. of grafts
Good
A (OS) 73/M Annular LK + conjunctival resection impending perforation 20/200 20/80 1B (OS) 60/M Conjunctival recession
Sectoral LKperipheral meltrecurrent melt
20/20 20/25 1
C (OS) 43/M Conjunctival recessionSectoral LK
unknown *peripheral melt
20/20 20/20 1
D 31/F Conjunctival resectionSectoral LKLamellar SKP
peripheral meltrecurrent meltrecurrent melt
20/20 20/40 2
E 48/M Sectoral LK + conjunctival resectionSectoral LK + conjunctival resection
impending perforationgraft infection
20/25 20/25 2
F (OD) 33/F Conjunctival recession peripheral melt 20/25 20/20 0F (OS) 33/F Conjunctival recession
Sectoral LK + conjunctival recessionperipheral meltrecurrent melt
20/25 20/25 1
G 58/F Sectoral LK peripheral melt 20/40 20/40 1H 55/M Sectoral LK + conjunctival resection impending perforation 20/40 20/40 1I 43/F Cornea glue
Conjunctival resection x2PK
impending perforationrecurrent meltperforated ulcer
20/30 20/20 1
Fair J 82/M Annular LK + conjunctival recession peripheral melt 20/70 CF 1K 55/F Corneal glue+conjunctival resection+sectoral LK perforated ulcer 20/60 CF 1L 90/M Lamellar SKP impending perforation PL PL 1M 66/M Sectoral LK x 2
Sectoral LK + central PKperforated ulcerrecurrent graft melt
HM CF 4
A (OD) 73/M Central LKSKP + conjunctival resection
impending perforationrecurrent melt
20/80 20/200 2
N 83/F Corneal glue + conjunctival resection + sectoral LK SKP
perforated ulcerinfected graft
CF PL 2
B (OD) 60/M Sectoral LKSectoral LK x3Conjunctival recession + AMT
impending perforationremelt, graft infectionrecurrent melt
20/40 CF 4
O (OD) 70/F Sectoral LKSectoral LK x 3Conjunctival recessionSKP x2
peripheral meltrecurrent meltrecurrent meltrecurrent melt
20/30 HM 5
P 38/F Conjunctival resection x3Sectoral LK x2; AMTCentral LK
peripheral meltperipheral meltrecurrent melt
20/20 CF 3
Q (OD) 69/F Sectoral LKPK x2
perforated ulcerperforated ulcer
20/70 20/400 3
Q (OS) 69/F Sectoral LK x2 impending perforation 20/40 CF 2R 55/F Sectoral LK impending perforation 20/30 20/70 1
Table: Baseline demographics, surgical procedures/indications, and visual outcome of the study patients
Final outcome
Patient Age/ Gender
Procedure Reason VA (Initial)
VA (Final)
No. of grafts
Poor S 62/F Sectoral LK + pterygium excisionPK + ICCESKPEvisceration
peripheral meltgraft infectiongraft infectiongraft infection
20/200 NPL 3
O (OS) 70/F Sectoral LK x3 recurrent melt 20/25 NPL 3C (OD) 43/M Gunderson flap
PKSKP + ECCESectoral LKPK + ACIOLWound washout + graft resutureEvisceration
unknown *unknown *perforated ulcer recurrent meltimpending perforationgraft infectiongraft infection
HM NPL 3
T 74/F Sectoral LK + conjunctival recessionEvisceration
peripheral melttotal corneal necrosis
HM NPL 1
VA - visual acuity CF: counting fingers, HM: hand motions, PL: projection of light, NPL: no projection of lightGender - M: male, F: female *: done in another centre
Thirteen eyes (50.0%) had repeat keratoplasty for recurrent melt Of 26 eyes, 23 were successfully salvaged with maintenance of
globe integrity 3 underwent evisceration for graft infection
Visual outcome was good to fair in 84.6% of eyes
Visual outcome
Number of eyes (%)
Good 10 (38.5%)
Fair 12 (46.2%)
Poor 4 (15.4%)**3 evisceration, 1 absolute glaucoma
Figure 1: Patient F (OS) with good visual outcome(a) Peripheral melt temporally
Figure 2: Patient P with fair visual outcome(a) Recurrence of peripheral melt after sectoral LK
(b) After sectoral LK (vision: 20/25)
(b) After central LK (vision: CF due to glaucoma)
Figure 3: Patient S with poor visual outcome(a) Sectoral LK with graft infection
(b) Infected SKP (Candida) (eventually underwent evisceration)
Discussion The role of surgery in the management of Mooren’s
ulcer has been described, though no definite trends are apparent due to several reasons, including Rarity of the disease Wide variety of surgical techniques employed Paucity on literature on the subject, with available reports
being limited by small numbers
Various surgical options have been described for therapeutic and tectonic purposes, including2-6 Superficial lamellar keratectomy Keratoepithelioplasty Lamellar keratoplasty Penetrating keratoplasty
Discussion Our study demonstrates that keratoplasty
with systemic immunosuppression restored globe integrity with good to fair visual retention in about 85% of eyes with advanced Mooren’s ulceration.
Poor outcome was related to recurrent melts from graft infection or relapse of Mooren’s ulceration Repeat keratoplasty appeared to carry a poorer
prognosisAdvanced glaucoma is another serious problem
Conclusion
Therapeutic keratoplasty should be considered in advanced cases of Mooren’s ulceration when conservative treatment fails to prevent disease progression.
References1) Sangwan VS, Zafirakis P, Foster CS. Mooren's ulcer: current concepts in management. Indian J Ophthalmol
1997;45(1):7-17.
2) Brown SI, Mondino BJ. Therapy of Mooren's ulcer. Am J Ophthalmol 1984;98(1):1-6.
3) Martin NF, Stark WJ, Maumenee AE. Treatment of Mooren's and Mooren's-like ulcer by lamellar keratectomy: report of
six eyes and literature review. Ophthalmic Surg 1987;18(8):564-9.
4) Kinoshita S, Ohashi Y, Ohji M, Manabe R. Long-term results of keratoepithelioplasty in Mooren's ulcer. Ophthalmology
1991;98(4):438-45.
5) Agrawal V, Kumar A, Sangwan V, Rao GN. Cyanoacrylate adhesive with conjunctival resection and superficial
keratectomy in Mooren's ulcer. Indian J Ophthalmol 1996;44(1):23-7.
6) Du Nian Z, Chen Jia Q, Gong Xian M, Xu Hong T. [Mooren's ulcer treated by lamellar keratoplasty (author's transl)].
Nippon Ganka Gakkai Zasshi 1979;83(10):1855-60.