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CASE REPORT OF MOOREN CORNEAL ULCER SECONDARY TO OCULAR TRAUMA.

 


Ebisike Philips Ifeanyichukwu (OD, MSc (Pharm), FAAO).

 

 

Introduction

Mooren ulcer (MU) is characterized by painful peripheral corneal ulceration of unknown etiology. The disease generally begins with intense limbal inflammation and swelling in the episcleral and conjunctiva1. Mooren ulcer is a painful, relentless, chronic ulcerative keratitis that begins peripherally and progresses circumferentially and centrally. It was named by Mooren who first clearly described this insidious corneal problem and defined it as a clinical entity2.

Corneal changes begin within 2-3 mm from the limbus, first appearing as grey swellings that rapidly furrow, affecting the superficial one-third of the cornea and then proceeding circumferentially and centrally over 4-12 months1,3. The bed of the furrow becomes vascularized, with vessels advancing into the base of the undermined edges of the ulcers1. These ulcers are often described as crescent-shaped and can leave behind an opaque and edematous central cornea. Alternatively, they can completely consume the corneal stroma, replacing it with a thin fibrovascular membrane3.

Inflammation is not seen in the sclera adjacent to the peripheral ulcers, nor does it affect the underlying Descemet’s membrane4. Destruction of the cornea generally affects stromal tissue only, leaving behind an intact endothelium and epithelium5. The central edges of the ulcer can develop an overhanging edge with or without opacification, and neovascularization of the cornea can occur, extending from the limbus into the ulcer bed3. Neovascularization can occur up to the advancing edge of the ulcer but not beyond it5.

Etiology

Although the etiology of Mooren’s ulcer is unknown, there is evidence suggesting an autoimmune basis, and possibly genetic and environmental factors contribute to the pathogenesis. Gottsch and colleagues have suggested that this disorder can result from a host response to calgranulin C, a normally hidden antigen expressed by keratinocytes in the corneal stroma. This molecule has also been found in circulating polymorphonuclear leukocytes6.

Risk Factors

Risk factors for Mooren's ulcer include corneal surgery, previous trauma, and infection. Although corneal surgery is a well-described risk factor, one study of 242 eyes affected by Mooren's ulcer in South India described an interesting caveat. In this study, Srinivasan and colleagues described 36 eyes that developed ulceration following extracapsular cataract extraction through a superior limbal incision; however, only 31% of these eyes developed ulceration at or contiguous to the site of the surgical wound. Nevertheless, this ratio of superior corneal involvement of Mooren's ulcer is still higher than expected when compared with 10% superior involvement found in eyes with no history of ocular surgery.

Epidemiology

Mooren ulcer is a rare disease. The incidence of MU in China was found to be 0.03%3. The disease is more common in the southern hemisphere including Southern and Central Africa and India, indicating a genetic and/or geographic predisposition5. Although it is generally agreed upon that Mooren's ulcer is more common in men, figures differ from one geographic population to the next in terms of age distribution. Studies from South India and China have suggested that patients tend to be affected between their sixth and eighth decades of life, with men being affected more than women by a ratio between 1.6:1 to 5:13,7.

However, this epidemiological picture may differ in African populations, as suggested by a study in Nigeria where the disease mostly affected men in their 20s-30s8. Another study from West Africa supported this epidemiologic finding, causing the authors to postulate that there were two distinct populations of patients with Mooren's ulcer9. The first population is older, more often develops unilateral disease, and responds to treatment whereas the second population is younger, tends to have bilateral disease which perforates more often, and does not respond to treatment. Also, as reported by Fasina and his associates in south-west Nigeria, that Mooren’s ulcer remains an uncommon disease in Ibadan, and the demographics and clinical presentation are similar to other parts of the West African sub-region10.




Pathophysiology

It has been postulated that Mooren’s ulcer may result from an autoimmune etiology. Sensitization to calgranulin C, an antigen expressed by corneal stromal keratinocytes, may occur after trauma or infection of the cornea, causing the unveiling of this hidden corneal antigen5. The unveiling of the hidden antigen may also occur naturally in predisposed people with aging. It has been hypothesized that antigen-presenting cells at the limbus can present the unveiled self-antigens via certain HLA class II molecules to T-cells, priming them. Alternatively, antigen-presenting cells may present a helminthic antigen that cross-reacts with calgranulin C (since certain helminths express receptors that bind calgranulin C) resulting in a similar reaction5. Later, upon injury of the cornea, humoral and cellular responses result in Mooren's ulcer4,5

Martin and colleagues have suggested that infection, trauma, or a systemic disease can expose corneal antigens and stimulate an immune response in which complement is activated and neutrophils degranulate and release collagenases. Collagenases then destroy the corneal stroma, further perpetuating the process by exposing more altered corneal antigens. Eventually, the entire cornea becomes consumed10. Evidence for a humoral immune response comes from a study that found circulating IgG against corneal and conjunctival epithelium in patients with Mooren's ulcer11. Studies have also found antibodies and complements bound to the conjunctival epithelium in addition to elevated serum IgA levels4.

Clinical Classification of Mooren Ulcer

There are various classifications of Mooren ulcer. One common classification divides the disease into two types based on laterality (one or two eyes) and age of onset:

§  Limited (benign) type: This type of MU doesn’t cause much pain or discomfort. It usually only happens in one eye (unilaterally). Only 25 percent of cases of the benign type happen in both (bilaterally). It’s more common if you are older.

 

§  Atypical (malignant) type: This type is more painful and can quickly cause the cornea to break down if it’s not treated. It usually happens in both eyes. About 75 percent of cases of the malignant type happen in both eyes.

More recent classifications grouped Mooren ulcer into three (3) types based upon their clinical presentation:

§  Unilateral Mooren's ulceration (UM). This is a painful and progressive corneal ulcer typically seen in elderly patients.

§  Bilateral aggressive Mooren's ulceration (BAM). This type occurs in young patients. The ulcer progresses circumferentially then centrally in the cornea.

§  Bilateral indolent Mooren's ulceration (BIM). This type usually occurs in middle-aged patients. It presents with progressive peripheral corneal ulceration in both eyes.

 

Diagnosis

The diagnosis of Mooren's ulcer requires the absence of any ocular infection or systemic rheumatological diseases known to cause peripheral corneal ulceration12. Srinivasan and colleagues described three patterns of ulceration: partial peripheral, complete peripheral, and total corneal ulceration (Figure A). In complete peripheral ulceration, the disease process has completely encompassed the corneal periphery, leaving behind a “central island of cornea” that is often opacified (Figure B). In total corneal ulceration, the corneal stroma has been completely replaced with a fibrovascular membrane (Figure C). Partial peripheral ulceration can be sub-divided into nasal, temporal, superior, and inferior ulceration, of which, temporal and nasal (the so-called intrapalpebral cornea) involvement is more common12.

 

Key: Figures; (A) Partial peripheral Mooren’s ulcer with a descemetocele within. Conjunctival and episcleral injection is present along with deep vessels in the base of the ulcer. A characteristic overhanging central ulcer margin is also seen.

 (B) Total peripheral Mooren’s ulcer with an edematous, opacified central cornea.

(C) Complete Mooren’s ulcer where a fibrovascular membrane has replaced the corneal stroma. (Figure reproduced from Srinivasan, Zegans, Zelefsky, Kundu, Lietman, Whitcher, and Cunningham. Adopted from the British Journal of Ophthalmology.)

History and Physical Examination

Patients often experience severe pain, photophobia, and tearing along with a red inflamed eye. About one third of cases present bilaterally13. A slit-lamp examination may reveal a crescent-shaped peripheral corneal ulcer with an undermined central edge. A linear epithelial defect may develop at the central margin, followed by progressive stromal melting. The ulcer progresses both circumferentially and centrally, resulting in a re-epithelialized, conjunctivalised thinned cornea13. Consequently, severe irregular astigmatism may result. Conjunctival and episcleral inflammation may occur; however, the sclera is spared. Decreased visual acuity can occur secondary to iritis, central corneal involvement, or irregular astigmatism2.

Differential Diagnosis

To diagnosed MU successfully, the following must be ruled out;

Terrien’s marginal degeneration differs from Mooren’s ulceration in that it is a painless, non-inflammatory disease, causing peripheral corneal thinning without ulceration. Terrien’s marginal degeneration also usually begins in the superior cornea (rather than the interpalpebral region) and proceeds circumferentially but not centrally. A clear zone with superficial vascularization remains between the limbus and the infiltrate4.

Pellucid marginal degeneration causes inferior corneal thinning and causes irregular against-the-rule astigmatism but lacks the inflammation and pain seen in Mooren's ulcer4. Senile furrow degeneration causes thinning between the limbus and an arcus in elderly patients; however, no inflammation or vascularization occurs4.

Rheumatoid arthritis can cause peripheral corneal ulcers that start as gray, swollen areas within 2 mm of the limbus1. Corneal thickness diminishes rapidly and may leave behind a fragile descemetocele. Angiography can show venous non-perfusion and disrupted limbal arcades with neovascularization reaching the base of the gutter. Scleritis may be associated, whereas Mooren's ulcer spares the sclera. Other findings in rheumatoid arthritis include keratoconjunctivitis sicca, episcleritis, and sclerosing keratitis4.

Keratolysis is a disease of central corneal stromal disintegration that is often seen in patients with long-standing rheumatoid arthritis. First, the central cornea swells and the epithelium begins to shed1. The disease process spreads until the corneal stroma is fully resorbed and a fragile Descemet’s membrane is left. This disease is generally painless.

Other collagen vascular diseases in which peripheral ulcerative keratitis can occur include systemic lupus erythematosus, systemic sclerosis, and relapsing polychondritis4. Peripheral ulcerative keratitis has also been reported to occur in association with inflammatory bowel disease, giant cell arteritis, staphylococcal marginal keratitis, HSV, and acanthamoeba keratitis.

Management

§  The initial treatment of Mooren’s ulcer consists of topical corticosteroids. Topical use of 1% or 2% Cyclosporine and interferon alfa 2 a were also suggested for the treatment of Mooren's ulcer13.

§  If corticosteroids do not control the inflammation, limbal conjunctival excision can be performed.

§  Conjunctival Excision of a 3-4 mm ring of limbal conjunctiva at least 2 clock hours adjacent to a Mooren's ulcer has been shown to be an effective treatment. Studies have shown that when less than half of the limbus is involved, the cure rate after conjunctival excision and corneal ulcer resection is performed is 51.3%. When more than half of the limbus is involved, the cure rate after the procedure decreases to 36.8%2.

§  In a 1975 study where limbal conjunctival excision was performed, 8 out of 10 eyes healed, and one developed recurring ulcer which then healed upon re-treatment13. It was hypothesized that the limbal conjunctiva may contain antibodies that react with antigens in the corneal stroma in addition to enzymes that destroy the corneal stroma -therefore, excision may interrupt the disease process.

§  Bilateral indolent Mooren’s ulceration often resolves with dietary changes and treatment of any systemic infection that may be present. It can also be treated with local steroids and cyclosporine A1.

§  Bilateral aggressive Mooren’s ulceration can also be treated with aggressive local and systemic immunosuppression.

§  Surgical interventions can also include lamellar keratoplasty, keratoepithelioplasty, delimiting keratotomy, and conjunctival flap and patch grafts using periosteum or fascia lata13.

§  Resection of the corneal lesion and adjacent conjunctiva combined with lamellar keratoplasty can achieve a final healing rate of 89.6%. If topical 1% cyclosporine A is added, a 95% final healing rate can be achieved2.

§  Cryotherapy to the conjunctiva surrounding ulcers may temporarily halt the progression of the disease, but healing may not occur until the conjunctiva is excised13. Other potential local therapies include bandage contact lenses, tissue adhesive, subconjunctival heparin, and artificial tears and collagenase inhibitors.

Complications

In addition to iritis being occasionally associated with Mooren’s ulceration, complications can include glaucoma, cataracts, and corneal perforation. Complicated cataracts can occur in 2.3%. The rate of perforation has varied in different studies in various geographical locations. Perforation occurs most often in the limbal cornea, followed by the peripheral and then central cornea2.

CASE REPORT

A 52 years old airport taxi man reported to the clinic with complain of severe pain in the left eye, associated with tearing, throbbing and pulling sensations. He also complained of fronto-temporal headache and sensitive to light. On inquiring, he said it started about ten days ago with itching, sandy sensation, gradual progressive pain, burning sensation with blurring vision and discomfort. According to him, he suddenly woke up with a swallowed and gummed eye. With further inquiry, he confirmed that he had a blunt trauma on the left eye some months ago (he claimed he applied some medication and all the associated trauma symptoms resolved). He is not hypertensive, diabetic and not aware of any systemic disease at the moment.

The Entering Visual Acuity (EVA) was OD: 6/12 and OS: LP. The anterior examination with slit lamp bimicroscopy with fluorescein stain showed a hyperaemic conjunctiva with concentric injections. A well stained concentric ulcer was seen at the center of the cornea with the based emanating or fanning towards the limbal areas of the cornea and anterior chamber appeared cloudy.

He was diagnosed with active corneal ulcer (Mooren ulcer suspected) and was placed on Moxifloxacin (4 hourly), Nepafenac, fluconazole eyedrops and Tobramycin ointment. He was also advised to return back to the clinic after one week.

N/B: Fluconazole eyedrop was added as my clinic protocol of managing any form of corneal ulcer on first day presentation with no confirmation of the causative isolate. Once after collection of corneal swabs for laboratory work-up, combined therapy of antibiotic, antifungal and antiviral if possible or when necessary, should commence immediately.

q  Highlight: He was placed on:

   Gutt: Moxifloxacin       gt          4hr             X           3/52

  Gutt:  Nepafenac            gt          q.i.d           X           3/52

   Gutt: Flucomid              gt          q.i.d           X           3/52

 Oct:   Tobramycin                        b.d.s          X           3/52


FOLLOW-UP #1

The patient reported back to the clinic after two weeks and four days with excuses of not being around and had taken a passenger to another state and was caught up with some security issues and circumstances. He reported that there was still pain, pulling sensations especially when he bends down, redness and reduced vision. Though he said there was quite improvement with the previous medication, especially in reducing the pain, excessive tearing and discharge within the first one week of applying the medications before leaving town on a trip.

His EVA was OD: 6/12 and OS: HM, slit lamp examination also revealed mild hyperaemic conjunctiva, round marked projection and thinning of the central portion of the cornea with leukoma. Also, the Descemet membrane of the cornea folds at the base of the ulceration with a central clear area within the area of thinning, the iris was not prolapsed and the anterior chamber appeared slightly deep. The Seidel test was negative indicating there was no perforation.

He was diagnosed of Mooren corneal ulcer with descemetocele and was asked to continue with moxifloxacin eyedrop and tobramycin ointment in addition of dexamethasone and timolol eyedrops, oral prednisolone 10mg twice daily. However, a bandage contact lens was placed on the eye to reduce the rubbing friction of the eyelid. He was asked to return back in one week for more evaluation and review.

N/B: Seidel test; This test is used to reveal leaks from the cornea, sclera, or conjunctiva following injury or surgery. It is named after the German ophthalmologist Erich Seidel (1882-1948).

  • Explain the procedure to the patient
  • Clean off the slit lamp and position the patient
  • Gently apply a topical anesthetic eye drop
  • Using a cotton tipped applicator, carefully dry the area of the suspected leak
  • Carefully apply a moistened fluorescein strip to the area of the suspected leak, "painting" on the dye. Alternatively, the dye can be applied to the superior conjunctiva, allowing the dye to flow down over the cornea
  • Visualize the injured site under a cobalt blue light source and evaluate for a green flow (positive Seidel test)
  • Estimate the rate and volume of fluid exiting the wound

 

Figure 1 showed a section of the slit lamp biomicroscopic examination during one of the follow-up visits.

 

FOLLOW-UP #2

The patient came back to the clinic with the report of much improvement, he admitted that the pain has subsided including discharge and tearing. His EVA was OD: 6/12 and OS: CF and slit lamp examination with and without contact lens, showed a well improved cornea compare with his last visit. Though there was a mild conjunctiva injection, the corneal thinning also looked well control especially with the help of the contact lens. The anterior chamber looked mildly cloudy with the iris been more quiet compare to his visit.

He was counselled and asked to continue with all his medication and oral prednisolone 10mg was tapered form twice to once daily and was asked to return back to the clinic after two weeks.

 

FOLLOW-UP #3

The patient came back to the clinic after two weeks with report of much improvement in most of his previous complains such as pain, pulling /throbbing sensation, photophobia, tearing and discharge. He only complained of mild itching occasionally and sandy sensations.

His EVA was OD: 6/12+1 and OS: 3/60, slit lamp examination revealed quieter and clearer conjunctiva, peripheral part of the cornea (ie., 1 - 3mm) appeared quiet and clear with concentric less dense leukoma and some fibrovascular tissues on the central portion of the cornea. The corneal thinning has reduced, iris appeared quiet and non-reactive, anterior chamber was less dense/cloudy, though there were slight flares seen in the anterior chamber.

He was also counselled and asked to discontinue with dexamethasone, tobramycin ointment and the contact lens, while he continued nepafenac, timolol, moxifloxacin, hypotears and the systemic prednisolone was also tapered from 10mg to 5mg once daily. The patient was referred for possible Cryotherapy in order to reduce the excessive fibrovascular tissues on the cornea.

 

 Figure 2 showed the appearance and condition of the eye before procedure.

CONCLUSION

As at the time of this case report, arrangement was made for the Cryotherapy procedure as I do get an update from the referred center. The patient is doing well with the same visual acuity. However, this also has updated the literature on the prevalence of Mooren corneal ulcer in our locality and also indicated that early presentation and appropriate diagnosis is the major factor in management of Mooren cornea ulcer, especially in preservation of the cornea form begin opacified or perforated.

 

 

 

REFERENCE

1.      Watson, P.G., Management of Mooren's ulceration. Eye (Lond), 1997. 11 (Pt 3): p. 349-56.

2.      Sangwan, V.S., P. Zafirakis, and C.S. Foster, Mooren's ulcer: current concepts in management. Indian J Ophthalmol, 1997. 45(1): p. 7-17.

3.      Chen, J., et al., Mooren's ulcer in China: a study of clinical characteristics and treatment. Br J Ophthalmol, 2000. 84(11): p. 1244-9.

4.      Taylor, C.J., et al., HLA and Mooren's ulceration. Br J Ophthalmol, 2000. 84(1): p. 72-5.

5.      Gottsch, J.D., et al., Cytokine-induced calgranulin C expression in keratocytes. Clin Immunol, 1999. 91(1): p. 34-40.

6.      Zelefsky, J.R., et al., Hookworm infestation as a risk factor for Mooren's ulcer in South India. Ophthalmology, 2007. 114(3): p. 450-3.

7.      Kietzman, B., Mooren's ulcer in Nigeria. Am J Ophthalmol, 1968. 65(5): p. 679-85.

8.      Wood, T.O. and H.E. Kaufman, Mooren's ulcer. Am J Ophthalmol, 1971. 71(1 Pt 2): p. 417-22.

9.      Fasina O, Ogundipe AO, and Ezichi EL. Mooren’s ulcer in Ibadan, Southwest Nigerian. J West Afr Coll Surg. 2013 Jul-Sep; 3(3): 102–119.

10.  Martin, N.F., W.J. Stark, and A.E. Maumenee, Treatment of Mooren's and Mooren's-like ulcer by lamellar keratectomy: report of six eyes and literature review. Ophthalmic Surg, 1987. 18(8): p. 564-9.

11.  Schaap, O.L., T.E. Feltkamp, and A.C. Breebaart, Circulating antibodies to corneal tissue in a patient suffering from Mooren's ulcer (ulcus rodens corneae). Clin Exp Immunol, 1969. 5(4): p. 365-70.

12.  Srinivasan, M., et al., Clinical characteristics of Mooren's ulcer in South India. Br J Ophthalmol, 2007. 91(5): p. 570-5.

13.  Alhassan, M.B., M. Rabiu, and I.O. Agbabiaka, Interventions for Mooren's ulcer. Cochrane Database Syst Rev, 2014. 1: p. CD006131.

 

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