BILATERAL DESTRUCTIVE MOOREN’S ULCER IN PREGNANCY AND MULTIDISCIPLINARY APPROACH TO MANAGEMENT: AN UNIQUE CASE REPORT

 To present a challenging case of Mooren’s ulcer in pregnancy, initially overlooked as inflamed pterygium and successfully managed with close liaison between ophthalmology, obstetrics and rheumatology teams.

Corneal and external disease services, Department of Ophthalmology, University Hospital Coventry and Warwickshire, Coventry, United Kingdom.

Retrospective Case report 

A 39-year-old African woman presented at 36-week gestation with acute onset bilateral decrease in vision, red, painful eyes associated with photophobia and epiphora. Initially, her eye symptoms were attributed to bilateral inflamed pterygium with dellen, and she was advised topical lubricants, surface steroids which did not help. On a closer look, slitlamp examination showed peripheral corneal thinning nasally in both eyes which was confirmed on anterior segment OCT. There was no scleral involvement and no evidence of uveitis. Blood investigations were unremarkable apart from a slightly low haemoglobin, raised ESR, CRP with negative autoimmune and systemic infection screen. To aid in diagnosis a conjunctival biopsy was also done which showed chronic inflammation of the conjunctiva with negative direct immunofluorescence in both eyes. Screening for deposition of IgM, IgG, IgA, C3 and fibrinogen was also negative. HLA typing was positive for HLA-DQ2 and negative for HLA-DR17.

A diagnosis of peripheral ulcerative keratitis- Mooren’s ulcer was established. Bilateral conjunctival resection with Amniotic membrane transplant was done. However, without systemic immunosuppression it was difficult to control her disease activity with topical steroids and local surgical management alone. Systemic methylprednisolone pulse dose followed by oral prednisolone was started under close supervision of the obstretics team and an early Caeserian section was done at 39-week gestation. Following this she was started on oral Mycophenolate under the guidance of rheumatologist. She achieved excellent visual recovery with resolution of active keratitis and stable peripheral thinning without corneal perforation.  

Mooren’s ulcer is an idiopathic painful peripheral ulcerative keratitis with devastating sequalae resulting in corneal perforation and sight loss.

Pregnancy poses a challenge to initiate cytotoxic therapy and effects of hormonal and immunological changes in pregnancy on disease activity can be difficult to manage.c

Mooren's ulcer can be successfully treated with good planning and multidisciplinary liaison between Ophthalmologists, Rheumatologists and Obstetricians.