Transcript SNEC Research Day

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
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
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.
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
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%)
Indications for surgery at presentation
Number of eyes
Impending globe perforation or perforated globe
9
Progressive peripheral corneal ulceration with failure of
maximal conservative treatment
17
Surgical procedures
Number of eyes
Conjunctival recession/resection
16
Tectonic/therapeutic keratoplasty
○ Semilunar LK
○ Central LK
○ PK
○ SKP
22
2
5
7
Table: Baseline demographics, surgical procedures/indications, and visual outcome of the study patients
Final
outcome
Good
Fair
Patient
A (OS)
B (OS)
Age/
Gender
73/M
60/M
C (OS)
43/M
D
31/F
E
48/M
F (OD)
F (OS)
33/F
33/F
G
H
I
58/F
55/M
43/F
J
K
L
M
82/M
55/F
90/M
66/M
A (OD)
73/M
N
83/F
B (OD)
60/M
O (OD)
70/F
P
38/F
Q (OD)
69/F
Q (OS)
R
69/F
55/F
Procedure
Reason
Annular LK + conjunctival resection
Conjunctival recession
Sectoral LK
Conjunctival recession
Sectoral LK
Conjunctival resection
Sectoral LK
Lamellar SKP
Sectoral LK + conjunctival resection
Sectoral LK + conjunctival resection
Conjunctival recession
Conjunctival recession
Sectoral LK + conjunctival recession
Sectoral LK
Sectoral LK + conjunctival resection
Cornea glue
Conjunctival resection x2
PK
Annular LK + conjunctival recession
Corneal glue+conjunctival resection+sectoral LK
Lamellar SKP
Sectoral LK x 2
Sectoral LK + central PK
Central LK
SKP + conjunctival resection
Corneal glue + conjunctival resection + sectoral LK
SKP
Sectoral LK
Sectoral LK x3
Conjunctival recession + AMT
Sectoral LK
Sectoral LK x 3
Conjunctival recession
SKP x2
Conjunctival resection x3
Sectoral LK x2; AMT
Central LK
Sectoral LK
PK x2
Sectoral LK x2
Sectoral LK
impending perforation
peripheral melt
recurrent melt
unknown *
peripheral melt
peripheral melt
recurrent melt
recurrent melt
impending perforation
graft infection
peripheral melt
peripheral melt
recurrent melt
peripheral melt
impending perforation
impending perforation
recurrent melt
perforated ulcer
peripheral melt
perforated ulcer
impending perforation
perforated ulcer
recurrent graft melt
impending perforation
recurrent melt
perforated ulcer
infected graft
impending perforation
remelt, graft infection
recurrent melt
peripheral melt
recurrent melt
recurrent melt
recurrent melt
peripheral melt
peripheral melt
recurrent melt
perforated ulcer
perforated ulcer
impending perforation
impending perforation
VA
(Initial)
20/200
20/20
VA
(Final)
20/80
20/25
No. of
grafts
1
1
20/20
20/20
1
20/20
20/40
2
20/25
20/25
2
20/25
20/25
20/20
20/25
0
1
20/40
20/40
20/30
20/40
20/40
20/20
1
1
1
20/70
20/60
PL
HM
CF
CF
PL
CF
1
1
1
4
20/80
20/200
2
CF
PL
2
20/40
CF
4
20/30
HM
5
20/20
CF
3
20/70
20/400
3
20/40
20/30
CF
20/70
2
1
Final
outcome
Poor
Patient
S
Age/
Gender
62/F
O (OS)
C (OD)
70/F
43/M
T
74/F
VA - visual acuity
Gender - M: male, F: female


Procedure
Reason
Sectoral LK + pterygium excision
PK + ICCE
SKP
Evisceration
Sectoral LK x3
Gunderson flap
PK
SKP + ECCE
Sectoral LK
PK + ACIOL
Wound washout + graft resuture
Evisceration
Sectoral LK + conjunctival recession
Evisceration
peripheral melt
graft infection
graft infection
graft infection
recurrent melt
unknown *
unknown *
perforated ulcer
recurrent melt
impending perforation
graft infection
graft infection
peripheral melt
total corneal necrosis
VA
(Initial)
20/200
VA
(Final)
NPL
No. of
grafts
3
20/25
HM
NPL
NPL
3
3
HM
NPL
1
CF: counting fingers, HM: hand motions, PL: projection of light, NPL: no projection of light
*: 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
Visual outcome Number of eyes (%)
Good
10 (38.5%)
Fair
12 (46.2%)
Poor
4 (15.4%)*
*3 evisceration, 1 absolute glaucoma
Figure 1: Patient F (OS) with
good visual outcome
(a) Peripheral melt temporally
(b) After sectoral LK
(vision: 20/25)
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
(b) After central LK
(vision: CF due to glaucoma)
(b) Infected SKP (Candida)
(eventually underwent evisceration)
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
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
Conclusion

Therapeutic keratoplasty should be
considered in advanced cases of
Mooren’s ulceration when conservative
treatment fails to prevent disease
progression.
References
1)
Sangwan VS, Zafirakis P, Foster CS. Mooren's ulcer: current concepts in management. Indian J Ophthalmol
1997;45(1):7-17.
2)
Brown SI, Mondino BJ. Therapy of Mooren's ulcer. Am J Ophthalmol 1984;98(1):1-6.
3)
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.
4)
Kinoshita S, Ohashi Y, Ohji M, Manabe R. Long-term results of keratoepithelioplasty in Mooren's ulcer. Ophthalmology
1991;98(4):438-45.
5)
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.
6)
Du Nian Z, Chen Jia Q, Gong Xian M, Xu Hong T. [Mooren's ulcer treated by lamellar keratoplasty (author's transl)].
Nippon Ganka Gakkai Zasshi 1979;83(10):1855-60.