Use Of Plasma Rich In Growth Factors (Prgf) Fibrine Membrane And Clot To Cover Neurotrophic Corneal Ulcer In Ocular Cicatricial Pemphigoid Associated With Systemic Lupus Erythematosus.

Ocular cicatricial pemphigoid (OCP) is an autoimmune disease characterized by chronic progressive conjunctival inflammation and scarring. These characteristics are common to a group of diseases that occur with chronic, systemic, inflammatory, subepithelial blistering, termed mucous membrane pemphigoid.

Mucous membrane pemphigoid has a female to male ratio of 2:1 and the average age of diagnosis is in the seventh decade of life. There is usually a delay in diagnosis of 2 years.

We present a case series of a neurotrophic ulcer secondary to ocular cicatricial pemphigoid in a patient with a history of systemic lupus treated with fibrin membrane rich in growth factors.

An 80-year-old woman referred to our cornea unit for a non-infiltrated corneal ulcer in her left eye with neurotrophic appearance secondary to cicatricial ocular pemphigoid.

She had systemic lupus erythematosus under internal medicine follow-up. She had had allergic reactions to tetracyclines and chloramphenicol.

Among her ocular history, she underwent cataract surgery in her right eye in 2015 and in her left eye in 2016. 

She was referred to the cornea unit due to acute presentation of a dull cornea with extensive central epithelial loss in the left eye, preserving 1-2 mm of peripheral corneal epithelium in 360º. Descemetic folds were observed, along with 360º corneal pannus, without signs of infiltration or infection. She was diagnosed with neurotrophic corneal ulcer. The best visual acuity in the left eye was 0.08. Treatment was initiated with gentamicin every 8 hours, autologous serum eye-drops, and insulin eye-drops. As there was no improvement, corneal coverage was decided with an amniotic membrane graft. After the amniotic membrane falls off one week after implantation, the described ulcer persisted. At this point, an implant of plasma rich in growth factors (PRGF) fibrin membrane and clot was decided to cover the epithelial defect. The implant is performed in the operating room. Additionally, plasma rich in growth factors eye-drops were used every 6 hours. At the 16-day follow-up visit, the patient no longer had the fibrin membrane implant. The examination showed a transparent cornea with peripheral pannus in the left eye. There were no epithelial defects or corneal thinning, and no signs of superficial keratitis. However, there was a white stromal deposit in the previous epithelial defect. Four months later, a transparent cornea with a similar appearance of white stromal deposit and intact epithelium persisted. Treatment with plasma rich in growth factors eye drops continued.

A new therapeutic option in preventing complications of OCP, such as the development of neurotrophic ulcers, is the use of plasma rich in growth factors (PRGF) fibrin membrane, clot, and eye drops. Several studies have demonstrated its effectiveness in treating refractory epithelial defects of neurotrophic ulcers, where autologous serum eye-drops and antibiotic therapy are not effective due to non-infectious ulcers. The use of PRGF eye drops has been shown to effectively close neurotrophic ulcers, with an average closure time of 11.4 weeks using the drop formulation. The effectiveness of PRGF fibrin membrane and PRGF clot has also been demonstrated in closing neurotrophic ulcers with greater corneal thinning or more severe symptoms.