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Mooren's Ulcer



·       It is a chronic, progressive and painful peripheral keratitis of idiopathic/unknown etiology and no systemic associations.

 

  • Autoimmune process - a Type 3 hypersensitivity reaction has been implicated - antigen antibody reaction to infectious toxin deposited in the peripheral cornea causes inflammation and ulceration

  • More common in adult males

 

  • Infectious associations have been reported- helminthiasis, hepatitis C


TYPES:

 

1.    Limited/Typical

Unilateral, older patients, mild to moderate symptoms, responded well to medical and surgical treatment


2.             Malignant/Atypical

Bilateral, younger patients, severe symptoms, poor response to therapy

 

Three zones of involvement:

 

Superficial stroma:

1.    Vascularised and infiltrated with plasma cells and lymphocytes

2.    Destruction of collagen matrix

3.    Absent epithelium and Bowman’s

 

Mid stroma:

1.    Fibroblast hyperactivity

2.    Collagen lamellae are disorganized

 

Deep stroma:

1.    Heavy macrophage infiltrate 

2.    Sparing of Descemet’s membrane and endothelium

 

SYMPTOMS:

 

  • Pain is excruciating - out of proportion to the inflammation

  • Redness, lacrimation, photophobia

  • Reduced vision - irregular astigmatism due to peripheral corneal thinning, associated uveitis, central corneal involvement

 

SIGNS:

  • Progressive, peripheral, crescentic corneal ulceration that is slightly central to the corneoscleral limbus

  • Patchy peripheral stromal infiltrates → Coalesce → spreads circumferentially and then centrally → involves limbus and entire cornea eventually


  • Anterior ⅓  to ½ of corneal stroma involved with a steep, overhanging edge

 

  • Leading and central edge is typically undermined 

 

  • Adjacent conjunctiva - inflamed


Lab investigations to rule out other peripheral ulcerative keratitis (PUK):


1.    CBC with differential count

2.    Platelet count

3.    ESR

4.    Rheumatoid factor

5.    ANA

6.    ANCA

7.    Complement fixation

8.    Circulating immune complexes

9.    VDRL/FTA-ABS

10.BUN and creatinine

 

TREATMENT:

 

Stepwise Approach

 

The goal of therapy is to arrest the destructive process and to promote healing and reepithelialization of the corneal surface


1.    Topical corticosteroids to control the inflammation

2.             Conjunctival resection

3.             Systemic immunosuppression

4.             Surgical procedures:


·       Superfical lamellar keratectomy

·       Small perforations can be sealed with glue and bandage contact lens

·       Patch graft/ penetrating keratoplasty is necessary in larger perforations not amenable to glue


Image from Rajan Eye Care Hospital



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