Moorens Ulcer With Secondary Fungal Keratitis - A Clinical And Surgical Dilemma

A 49 year old gentleman presented with pain, redness and watering in the RE since 6 months. He was diagnosed elsewhere with Moorens ulcer and inadequately treated for the same. After presentation, he received 3 doses of intravenous methyl prednisolone and initiated on topical and systemic steroids and methrotrexate. His eye responded well to treatment. 5 months later, he presented with increased pain and redness in the same eye. Clinical examination revealed a stromal infiltrate with feathery margins and scraping confirmed the presence of fungal filaments on smear. His topical steroids were stopped and he was started on topical and oral antifungals. Oral Methotrexate was also discontinued. The infiltrate showed slow response to therapy, but there was significant ongoing melt of the underlying stroma. This led to the dilemma of the melt being due to worsening of the fungal keratitis or the Moorens ulcer. Considering the clinical appearance, we concluded that it was a worsening of the Moorens ulcer and the patient was restarted on oral immunusuppression.

He then underwent a crescentric patch graft for tectonic stability under the cover of oral immunosuppression and topical antifungals. Other options for tectonic stability are multilayered amniotic membrane grafts; however in view of the extent of involvement, a corneal patch graft was deemed necessary in this scenario. The patient responded well to the treatment with no recurrence of the Moorens ulcer or fungal keratitis.