Perforated Mooren’S Ulcer : How To Make Freeze Dried Amniotic Membrane Grafting A Success

Mooren’s ulcer is an isolated corneal thinning in a peripheral crescent-shape. It can lead to vision loss due to corneal opacities and, in complicated cases, to corneal perforation. Medical treatment with steroids and immunosuppressants necessitates in complicated cases additional surgical procedures to preserve globe integrity, mainly corneal lamellar grafting, fresh amniotic membrane or keratoplasty. The recent use of freeze-dried amniotic membrane in Mooren's ulcer has proved successful especially in uncomplicated cases, but results varied in perforated corneas. We describe through our case the successful use of freeze-dried amniotic membrane in a perforated Mooren’s ulcer using a simplified surgical technique.

20th August Hospital, CHU Ibn Rochd University Hospital.

A 40 y-o female presented to the emergencies for a painful red eye. Initial exam found a BCVA of 0.4, a corneal perforation of 3x3mm with iris prolapse within a marginal corneal thinning. Laboratory tests ruled out systemic diseases. The patient was treated with steroids and immunosuppressants with no improvement. Conjunctival advancement flap was unsucessful, so was the first attempt of freeze-dried amniotic membrane graft. We decided to use a different technique : lamellar stromal dissection around the perforation, multi-layered intrastromal graft secured with 10-0 nylon. The postop course had progressive restitution of the corneal thickness and visual acuity : VA was 0.8 and corneal thickness 412 µ at the perforation site after 6 months.

Mooren’s ulcer is an immune-mediated destruction of the peripheral corneal stroma that cannot be linked to a systemic autoimmune. The therapeutic challenge lies in the restoration of tissue loss especially in perforated corneas. Options include cyanoacrylate glue, fibrin glue, fresh amniotic membrane in small perforations (<1-3mm), scleral or corneal grafts, lamellar or penetrating keratoplasty in larger perforations (>3mm). The recent use of freeze-dried amniotic membrane simplified access to therapeutic options when organ banks or grafts are unavailable. It is used to reduce inflammation and accelerate re-epithelialization of the ulcer. However, its use in large perforated Mooren’s ulcers had unconclusive outcomes in literature.

Multi-layered freeze-dried amniotic membrane graft can be an effective surgical modality in the treatment of perforated Mooren’s ulcer in mid-sized to larger perforations if managed properly.

Our observation displays the importance of adapting the surgical technique to the pathophysiological substrate of Mooren’s ulcer through treating every aspect : immunomodulated inflammation reduced by conjunctivectomy and debridement, tectonic support using multilayers and secured sutures.

Early diagnosis and immunosuppression remains essential in avoiding such complication and simplifying later surgical management.