The EBAI CME 2013 - 21st and 22nd of September 2013, Golden Valley Resort, Ghodbunder Road, Thane West, Mumbai.

1. Mooren’s Ulcer
The Step Ladder Approach
Jatin Ashar
Mumbai Eye Care, Cornea and LASIK Centre

2. Layout
Introduction
Demographics
Etiopathogenesis
Clinical features
Mimics
Management
Speical situations-cataract surgery and pediatric patients

3. Introduction
Peripheral ulcerative keratitis with no scleral involvement
‘Ulcus Rodens’ Brown and McKenzie
Painful, relentless, aggressive course
Steep overhanging central edge
Strats peripherally and eventually spreads circumferentially and
centripetally

4. Demographics
STUDY Arvind Study1
China Study2
L V P E I Study3
Subjects 242 eyes of 166 patients 715 eyes of 550 patients 244 eyes of 145 patients
M:F 137:29 318:232 125:20
Age 13-95 yrs 14-79 yrs 10-74 yrs
Risk factors Prior surgery, trauma Trauma, prior surgery Trauma
Laterality Bilateral patients older
than unilateral
Bilateral patients older
and more severe
1. Srinivas M, et al. BJO 2007
2. Chen N, et al. BJO 2000
3. Mathur A, Ashar J, Sangwan V (Unpublished data)

5. Etiopathogenesis
Still elusive
Autoimmune theory-cell mediated and humoral
Histopathological evidence of plasma cell infiltration in
superficial stroma, hyperactivity of fibroblasts in mid stroma,
macrophage infiltration in deep stroma

6. Etiopathogenesis
LYMPHOCYTI
C
INFILTRATI
ON

7. Clinical Features
Pain
Redness
Tearing
Photoph obia
Decreased visual acuity

8. signs
Peripheral patchy infiltrates
Epithelial defect
Shallow furrow
Limbal invovlement
Steep overhaning edge
Circumferential spread and centripetal spread

10. Investigations
Clinical features
Rule of infectious process
Systemic collagen vascular diseases-CBC, ESR, RA, ANA,
VDRL, ANCA, XRAY Chest
Systemic evaluation by physician

11. Mimics
Infectious keratitis
Marginal keratitis
Rheumatoid arthritis
Wegener’s granulomatosis
Terrien’s degeneration

12. Management
Medical management
Surgical management

13. Medical Management
Topical steroids
Systemic steroids- oral
Systemic steroids- intravenous pulse Methyl prednisolone
Systemic immunomodulators- oral Methotrexate,
Cyclophosphamide, Azathioprine
Systemic immunomodulators- intravenous pulse
cyclophosphamide

14. Topical Steroids
Initial therapy
Hourly prednisolone acetate 1%
Monitor epithelial healing
Add prophylactic antibiotic

15. Systemic Immunosuppression
Oral steroids- prednisolone 1mg/kg
Cyclophosphamide 2mg/kg/day
Methotrexate 7.5-12.5mg/week
Azathioprine 2mg/kg/day
Cyclosporine 10mg/kg/day

17. Step Ladder Approach for
Immunosuppression
Step 1: Assess disease severity
Step 2: Severity based therapy
Step 3: Regular follow up and monitoring
Step 4: Reassess and modify therapy when needed

18. Severity of Mooren’s ulcer
Number of clock hours
Depth of stromal involvement
• Clock hour based
< 6 clock hours (2 quadrants)
> 6 clock hours (2 quadrants)
• Depth based
<50% stromal loss
>51-95% stromal loss
>95% and perforation

20. Complications:
• Most common complication – infection
• Recurrence of disease

21. Outcome of Step Ladder
Immunosuppression Approach
Immunosuppression Number of cases
receiving the therapy
Success rate #
Keratoplasty needed+
Topical steroids 145
Topical steroids alone 62 76% 3
Oral steroids 66 86% 12
Oral Methotrexate 14 78.5% 3
IVMP 7 71.4% 2
IVMP+IV
cyclophosphamide
15 73.3%
# Success defined as resolution of disease
+ Indicator of worsening of disease leading to perforation or severe thinning threatening the tectonic stability of cornea

22. Surgical Therapy
Conjunctival resection-2 clock hours either sides and 4mm
posterior to limbus
Superficial keratectomy
Tissue adhesive
Bandage contact lens

23. Surgical Therapy
Amniotic membrane transplantation
Patch graft
Lamellar keratoplasty
Penetrating keratoplasty
Keratoprosthesis

24. Surgical Therapy

25. AMT for Mooren’s Ulcer

26. Surgical Therapy

27. Outcomes of Patch graft

28. Surgical Therapy

29. Surgical Therapy

30. Surgical Therapy

31. Surgical Therapy

32. Surgical Therapy
Cataract surgery

33. Special situations
• Pediatric population

34. Conclusion
• Mooren’s ulcer is often recalcitrant and aggressive disorder
• A multimodality management is required to bring the disease
under control
• Immunosuppression is paramount to disease control
• A systematic step ladder approach offers good results

35. • THANK YOU