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| PHOTO ESSAY |
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| Year : 2022 | Volume
: 2
| Issue : 1 | Page : 259-260 |
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Tissue remodelling in end stage Mooren's ulcer
Uma Y Thigale, Aravind Roy
Cornea and Anterior Segment Services, KVC Campus, L V Prasad Eye Institute, Vijayawada, Andhra Pradesh, India
| Date of Submission | 30-May-2021 |
| Date of Acceptance | 07-Sep-2021 |
| Date of Web Publication | 07-Jan-2022 |
Correspondence Address:
Dr. Aravind Roy
Cornea and Anterior Segment Services, KVC Campus, L V Prasad Eye Institute, Vijayawada, Andhra Pradesh - 521 137
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijo.IJO_1480_21
Keywords: Conjunctival resection, immunosuppression, Mooren's ulcer, tissue remodeling
How to cite this article:
Thigale UY, Roy A. Tissue remodelling in end stage Mooren's ulcer. Indian J Ophthalmol Case Rep 2022;2:259-60 |
A 40-year-old woman presented with severe pain, redness, and blurring of vision in both eyes since one year. Best-corrected visual acuity (BCVA) in right eye (RE) was 20/80 and left eye (LE) was 20/25. Slit-lamp examination of both eyes revealed peripheral corneal ulceration with thinning, involving 3–7-o'clock and 2–7-o'clock limbus in RE and LE, respectively, without scleral involvement [Figure 1]a and [Figure 1]b. Rest of anterior and posterior segment examination was within normal limits in both eyes. She was advised systemic investigations and physician consultation to rule out autoimmune etiology. All laboratory tests were negative. The patient was not keen on physician consultation and oral immunosuppressants could not be initiated. She was diagnosed with bilateral Mooren's ulcer. We advised bilateral conjunctival resection with tissue adhesives and bandage contact lens. Topical 1% prednisolone acetate eight times in tapering doses and 0.5% moxifloxacin four times were administered. At 16 months, bilateral total corneal involvement was noted with visual acuity of hand motions [Figure 2]a and [Figure 2]b. The patient was lost to follow-up for 14 months and was not using any medications. On last follow-up of 59 months, the cornea had remodeled sufficiently, leaving behind a thin stroma with minimum scarring and vascularization [Figure 3]a and [Figure 3]b. BCVA and central corneal pachymetry were 20/400, 420μ in RE and 20/400, 304μ in LE [Figure 4]a and [Figure 4]b. She was advised visual rehabilitation, topical lubricants and six monthly review. | Figure 1: (a) Right and (b) left eye at presentation, with peripheral corneal ulceration, overhanging edges without scleral involvement
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 | Figure 2: (a) Right and (b) left eye at 16 months follow-up with central corneal island, vascularization, and thinning (End-stage Mooren's ulcer)
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 | Figure 3: (a) Right eye and (b) left eye at last follow up of 59 months, with extensive tissue remodeling, with corneal thinning
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 | Figure 4: (a) Anterior segment optical coherence tomography of right and (b) left eye showing uniform corneal thinning at last follow up of 59 months
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| Discussion | |  |
End-stage Mooren's ulcer resolves, leaving behind a thin, scarred, and vascularized cornea. Management requires a multidisciplinary approach with rheumatologist and ophthalmologist.[1] Presence of macrophage migration inhibition response and circulating antibodies to the conjunctiva and corneal epithelium is suggestive of cell-mediated and autoimmune phenomena responsible for the immunopathogenesis of Mooren's ulcer.[2] PMNs' infiltrate the edematous cornea in advanced stages of the disease; collagenases and lysosomal cell-mediated hydrolases cause disruptions of stromal collagen fibrils in superficial stroma that are replaced with amorphous fine fibrillar substance. Electron microscopy studies showed that the posterior stroma is relatively unaffected.[3],[4] Tissue remodeling leads to a thin atrophic scar, allowing limited vision and relative tectonic stability. Mooren's ulcer requires an immunosuppressive regimen that is adjusted to the disease severity. Our case highlights that tissue remodeling without active intervention may significantly alter corneal scarring and leave behind thin corneas with acceptable vision and cosmesis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Hyderabad Eye Research Foundation.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Sangwan VS, Zafirakis P, Foster CS. Mooren's ulcer: Current concepts in management. Indian J Ophthalmol 1997;45:7-17.  [ PUBMED] [Full text] |
| 2. | Mondino BJ, Brown SI, Rabin BS. Cellular immunity in Mooren's ulcer. Am J Ophthalmol 1978;85:788-91. |
| 3. | Brown SI, Mondino BJ, Rabin BS. Autoimmune phenomenon in Mooren's ulcer. Am J Ophthalmol 1976;82:835-40. |
| 4. | Young RD, Watson PG. Light and electron microscopy of corneal melting syndrome (Mooren's ulcer). Br J Ophthalmol 1982;66:341-56U. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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