High-Risk Mooren’S Ulcer: Therapeutic Dilemmas And Clinical Decision-Making In Five Cases

Mooren’s ulcer is a rare, progressive, immune-mediated peripheral ulcerative keratitis associated with significant diagnostic and therapeutic challenges. Management is especially difficult in high-risk patients due to uncertainty regarding oral immunosuppression, coexistence or history of ocular infectious disease, and risk of corneal perforation. We present five challenging cases of Mooren’s ulcer highlighting key therapeutic dilemmas and clinical decision-making strategies.

Cornea-Uveitis Department, S. Malayan Eye Center, Yerevan, Armenia.

Between 2023-2025 we have treated 8 patients with Mooren’s ulcer, 5 of whom represented a spectrum of high-risk clinical scenarios, including almost 360° involving peripheral corneal perforation in a patient with severe osteoporosis, a patient with coexisting chronic dacryocystitis requiring therapeutic sequencing, diagnostic uncertainty in the setting of a patient with prior herpetic keratitis, and two elderly female patients (79 y.o. and 82 y.o.) for initiation of oral immunosuppression.
Workup included corneal scraping, PCR to exclude infections, systemic exam to rule out autoimmune diseases. Management was focused on individualized risk–benefit assessment regarding systemic immunosuppression, sequencing of surgical vs medical treatment.

Major dilemmas included avoidance of systemic immunosuppression in severe osteoporosis, sequencing treatment in the presence of chronic dacryocystitis, differentiation from herpetic keratitis, and initiation of immunosuppression in elderly patients. Systemic therapy was individualized, 4 of 5 patients underwent amniotic membrane transplantation (AMT) combined with tailored medical therapy, which included oral Doxycycline, oral steroids, Azathioprine, and antiviral prophylaxis in a patient with h/o herpetic disease. Oral steroids were tapered in 10-12 weeks, whereas Azathioprine was continued for 6-9 months. Oral Doxycycline was discontinued in 6 weeks. All ulcers gradually healed in 6-12 weeks.

Management of high-risk Mooren’s ulcer requires individualized approach and clinical decision-making based on patient comorbidities, diagnostic uncertainty, particularly in elderly patients where the risks of systemic immunosuppression should be cautiously considered. Careful integration of surgical procedure with tailored medical therapy can result in successful outcomes even in challenging situations. These cases highlight the importance of case-oriented treatment strategies in managing Mooren’s ulcer.