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.

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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

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