Mooren’s Ulcer

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

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Mooren’s Ulcer

  1. 1. Mooren’s Ulcer The Step Ladder Approach Jatin Ashar Mumbai Eye Care, Cornea and LASIK Centre
  2. 2. Layout Introduction Demographics Etiopathogenesis Clinical features Mimics Management Speical situations-cataract surgery and pediatric patients
  3. 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. 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 Mathur A, Ashar J, Sangwan V (Unpublished data)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. 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. 6. Etiopathogenesis LYMPHOCYTI C INFILTRATI ON
  7. 7. Clinical Features Pain Redness Tearing Photoph obia Decreased visual acuity
  8. 8. signs Peripheral patchy infiltrates Epithelial defect Shallow furrow Limbal invovlement Steep overhaning edge Circumferential spread and centripetal spread
  9. 9. Investigations Clinical features Rule of infectious process Systemic collagen vascular diseases-CBC, ESR, RA, ANA, VDRL, ANCA, XRAY Chest Systemic evaluation by physician
  10. 10. Mimics Infectious keratitis Marginal keratitis Rheumatoid arthritis Wegener’s granulomatosis Terrien’s degeneration
  11. 11. Management Medical management Surgical management
  12. 12. Medical Management Topical steroids Systemic steroids- oral Systemic steroids- intravenous pulse Methyl prednisolone Systemic immunomodulators- oral Methotrexate, Cyclophosphamide, Azathioprine Systemic immunomodulators- intravenous pulse cyclophosphamide
  13. 13. Topical Steroids Initial therapy Hourly prednisolone acetate 1% Monitor epithelial healing Add prophylactic antibiotic
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. Complications: • Most common complication – infection • Recurrence of disease
  18. 18. 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
  19. 19. Surgical Therapy Conjunctival resection-2 clock hours either sides and 4mm posterior to limbus Superficial keratectomy Tissue adhesive Bandage contact lens
  20. 20. Surgical Therapy Amniotic membrane transplantation Patch graft Lamellar keratoplasty Penetrating keratoplasty Keratoprosthesis
  21. 21. Surgical Therapy
  22. 22. AMT for Mooren’s Ulcer
  23. 23. Surgical Therapy
  24. 24. Outcomes of Patch graft
  25. 25. Surgical Therapy
  26. 26. Surgical Therapy
  27. 27. Surgical Therapy
  28. 28. Surgical Therapy
  29. 29. Surgical Therapy Cataract surgery
  30. 30. Special situations • Pediatric population
  31. 31. 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
  32. 32. • THANK YOU

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