Mooren’S Ulcer - A Tough Case To Manage

The aim of this report is to present the diagnostic and therapeutic approach to a case of recurrent unilateral peripheral ulcerative keratitis.

Ophthalmology Department and Rheumatology Department, Hospital de Egas Moniz, Unidade Local de Saúde Lisboa Ocidental, Portugal.

Retrospective description of a clinical case. A 38-year-old female presented with a history of unilateral ocular pain, redness, and foreign body sensation in her left eye in the previous week. No prior ocular or systemic history were documented. The left eye exhibited marked nasal bulbar conjunctival injection, and a circumferential perilimbic corneal ulcer with neovascularization in its base. Physical examination and history did not reveal any abnormalities. Extensive laboratory investigations unveiled positive anti-centromere and anti-nuclear antibodies, while capillaroscopy, chest CT and echocardiogram were unremarkable. 

A diagnosis of Mooren's ulcer was suspected and treatment was initiated with intensive ocular lubrication, topical ciclosporin, oral doxycycline and a combination of topical and oral steroids. The ulcer exhibited favorable progression initially; however, deterioration was noted 2 weeks after the patient decided to stop all therapy. There was no clinical improvement upon reinstitution of the medical therapy previously described. Hence, the patient undergone surgical intervention: perilimbic conjunctival and Tennon resection (with 2 mm margin from the limit of neovascularization) and amniotic membrane graft placement. In addition, the patient was started on Methotrexate for safe oral steroid taper.

This case underscores the complexity and challenges associated with Mooren's corneal ulcer diagnosis and management, demonstrating the need for a multidisciplinary approach involving medical, surgical, and immunomodulatory strategies.