Surgical Management of Advanced Mooren’s Ulceration

1. Pui Yi Boey1, Seng-Ei Ti1, Donald TH Tan1,2 1Singapore Eye Research Institute, Singapore National Eye Centre 2Dept 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 National Eye Centre Singapore Eye Research Institute Surgical Management of Advanced Mooren’s Ulceration

2. 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

3. 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.

4. 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

5. 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%)

6. Table: Baseline demographics, surgical procedures/indications, and visual outcome of the study patients

7. VA - visual acuity CF: counting fingers, HM: hand motions, PL: projection of light, NPL: no projection of light Gender - 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

8. Figure 2: Patient P with fair visual outcome (a) Recurrence of peripheral melt after sectoral LK Figure 3: Patient S with poor visual outcome (a) Sectoral LK with graft infection Figure 1: Patient F (OS) with good visual outcome (a) Peripheral melt temporally (b) After central LK (vision: CF due to glaucoma) (b) After sectoral LK (vision: 20/25) (b) Infected SKP (Candida) (eventually underwent evisceration)

9. 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

10. 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 prognosis • Advanced glaucoma is another serious problem

11. Conclusion • Therapeutic keratoplasty should be considered in advanced cases of Mooren’s ulceration when conservative treatment fails to prevent disease progression.

12. References • Sangwan VS, Zafirakis P, Foster CS. Mooren's ulcer: current concepts in management. Indian J Ophthalmol 1997;45(1):7-17. • Brown SI, Mondino BJ. Therapy of Mooren's ulcer. Am J Ophthalmol 1984;98(1):1-6. • 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. • Kinoshita S, Ohashi Y, Ohji M, Manabe R. Long-term results of keratoepithelioplasty in Mooren's ulcer. Ophthalmology 1991;98(4):438-45. • 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. • Du Nian Z, Chen Jia Q, Gong Xian M, Xu Hong T. [Mooren's ulcer treated by lamellar keratoplasty (author's transl)]. Nippon GankaGakkaiZasshi 1979;83(10):1855-60.