Management Of A Case Of Mooren's Ulcer

The purpose of this paper is to describe the case of a woman, without significant systemic pathologies, except for a thyroid pathology, who presented to our observation with a history of a nasal corneal perforation in the right eye without a precise diagnosis. 

The patient reported surgery with a corneal patch for tectonic purposes and systemic therapy with antivirals and local therapy with antibiotics and autologous serum-based eyedrops.

Both eyes, and in particular the right eye, showed conjunctival hyperemia, tearing and eyelid edema.  

The patient complained of severe pain and of not seeing with her right eye.

Ophthalmic Department Asl Roma 2, S.Eugenio Hospital

We decided to submit the patient to a new deeper lamellar keratoplasty for optical purposes in the right eye, but while waiting for the surgery we noticed a quick worsening of the left eye with an increase in conjunctival hyperemia and a marked nasal corneal thinning and so we started a therapy with antibiotic-steroid eye drops, artificial tears and gel in the left eye without improvement.

During the surgery of the right eye we noticed limbar thinning also in the upper and lower cornea, so we decided not to deepen the keratoplasty too much and we diagnosed Mooren's ulcer. The day after surgery the cornea was clear but after two days we noticed an initial nasal melting and so we decided to start systemic steroid therapy without improvement.

Considering carefully the risks and benefits of immunosuppressive therapies, we prescribed mycophenolate tablets 250 mg times a day and frequent blood count and renal function checks.

After two days conjunctival hyperemia,tearing, eyelid edema of both eyes, corneal melting of the right eye and corneal thinning of the left eye began to improve. After a few days the cornea of the left eye repaired with the onset of conjunctival fibrosis and also the right eye began to stabilize.
Therapy with mycophenolate was continued for 3 months and then discontinued because the patient complaining of lower limb disorders. The disease remained stable at 6 and 9 month follow up.

In the event of a sudden onset of bilateral nasal corneal thinning and perforations, even if asymmetrical, it is important to recognize Mooren's ulcer and to start systemic therapy with immunosuppressants early. In our case, mycophenolate made it possible to keep the disease under control in the absence of significant side effects.