1. Pui Yi Boey 1, Seng-Ei Ti 1, Donald TH Tan 1,2 1 Singapore Eye Research Institute, Singapore National Eye Centre 2 Dept of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore The authors have no financial interest in the subject matter of this e-poster. Singapore Eye Research Institute Singapore National Eye Centre

2. Introduction  The management of Mooren’s ulcer is difficult due to its progressive and relapsing nature.  The goal of therapy is directed at controlling inflammation and preserving globe integrity.  A stepwise approach in its management has been suggested, which includes topical steroids, conjunctival resection, systemic immunosuppression and lastly, surgery. 1  There is no consensus on the role of surgery  Some authors reserve surgical intervention for end-stage disease  Others advocate the use of different surgical procedures to preserve tectonic integrity of the globe, as well as for therapeutic reasons, by removing corneal antigenic targets in the hope of arresting the inflammatory process. 2-4

3. Purpose  To review the surgical management, visual outcome and complications of management of advanced Mooren’s ulceration in Asian eyes in a tertiary eye centre.

4. Methods  Retrospective case notes review of patients requiring surgery for advanced Mooren’s ulceration from 1992 to 2009  The following data were collected Indications and type of surgical procedure Conjunctival resection Lamellar keratoplasty (LK) Penetrating keratoplasty (PK) Sclerokeratoplasty (SKP) Concurrent medical treatment Recurrence of disease  Outcome was assessed in terms of globe integrity and visual acuity at last follow-up  Visual outcome was defined as Good: Best-corrected visual acuity (BCVA) improved or maintained within 3 Snellen lines Fair: Loss of BCVA by 3 Snellen lines with maintained globe integrity Poor: Loss of vision or globe integrity

5. Results  26 eyes of 20 patients were included  12 females, 8 males  Mean age 59.1 (SD 16.4) years (range 31-90)  Mean follow-up time 63.7 (+/- 47.7) months  Preoperatively, topical or systemic immunosuppression was administered in 18 eyes (69.2%) Indications for surgery at presentationNumber of eyes Impending globe perforation or perforated globe9 Progressive peripheral corneal ulceration with failure of maximal conservative treatment 17 Surgical proceduresNumber of eyes Conjunctival recession/resection16 Tectonic/therapeutic keratoplasty ○Semilunar LK ○Central LK ○PK ○SKP 22 2 5 7

6. Final outcome PatientAge/ Gender ProcedureReasonVA (Initial) VA (Final) No. of grafts Good A (OS)73/MAnnular LK + conjunctival resectionimpending perforation20/20020/801 B (OS)60/MConjunctival recession Sectoral LK peripheral melt recurrent melt 20/2020/251 C (OS)43/MConjunctival recession Sectoral LK unknown * peripheral melt 20/20 1 D31/FConjunctival resection Sectoral LK Lamellar SKP peripheral melt recurrent melt 20/2020/402 E48/MSectoral LK + conjunctival resection impending perforation graft infection 20/25 2 F (OD)33/FConjunctival recessionperipheral melt20/2520/200 F (OS)33/FConjunctival recession Sectoral LK + conjunctival recession peripheral melt recurrent melt 20/25 1 G58/FSectoral LKperipheral melt20/40 1 H55/MSectoral LK + conjunctival resectionimpending perforation20/40 1 I43/FCornea glue Conjunctival resection x2 PK impending perforation recurrent melt perforated ulcer 20/3020/201 FairJ82/MAnnular LK + conjunctival recessionperipheral melt20/70CF1 K55/FCorneal glue+conjunctival resection+sectoral LKperforated ulcer20/60CF1 L90/MLamellar SKPimpending perforationPL 1 M66/MSectoral LK x 2 Sectoral LK + central PK perforated ulcer recurrent graft melt HMCF4 A (OD)73/MCentral LK SKP + conjunctival resection impending perforation recurrent melt 20/8020/2002 N83/FCorneal glue + conjunctival resection + sectoral LK SKP perforated ulcer infected graft CFPL2 B (OD)60/MSectoral LK Sectoral LK x3 Conjunctival recession + AMT impending perforation remelt, graft infection recurrent melt 20/40CF4 O (OD)70/FSectoral LK Sectoral LK x 3 Conjunctival recession SKP x2 peripheral melt recurrent melt 20/30HM5 P38/FConjunctival resection x3 Sectoral LK x2; AMT Central LK peripheral melt recurrent melt 20/20CF3 Q (OD)69/FSectoral LK PK x2 perforated ulcer 20/7020/4003 Q (OS)69/FSectoral LK x2impending perforation20/40CF2 R55/FSectoral LKimpending perforation20/3020/701 Table: Baseline demographics, surgical procedures/indications, and visual outcome of the study patients

7. Final outcome PatientAge/ Gender ProcedureReasonVA (Initial) VA (Final) No. of grafts PoorS62/FSectoral LK + pterygium excision PK + ICCE SKP Evisceration peripheral melt graft infection 20/200NPL3 O (OS)70/FSectoral LK x3recurrent melt20/25NPL3 C (OD)43/MGunderson flap PK SKP + ECCE Sectoral LK PK + ACIOL Wound washout + graft resuture Evisceration unknown * perforated ulcer recurrent melt impending perforation graft infection HMNPL3 T74/FSectoral LK + conjunctival recession Evisceration peripheral melt total corneal necrosis HMNPL1 VA - visual acuityCF: counting fingers, HM: hand motions, PL: projection of light, NPL: no projection of light Gender - M: male, F: female*: done in another centre  Thirteen eyes (50.0%) had repeat keratoplasty for recurrent melt  Of 26 eyes, 23 were successfully salvaged with maintenance of globe integrity  3 underwent evisceration for graft infection  Visual outcome was good to fair in 84.6% of eyes Visual outcomeNumber of eyes (%) Good10 (38.5%) Fair12 (46.2%) Poor4 (15.4%)* *3 evisceration, 1 absolute glaucoma

8. Figure 1: Patient F (OS) with good visual outcome (a) Peripheral melt temporally Figure 2: Patient P with fair visual outcome (a) Recurrence of peripheral melt after sectoral LK (b) After sectoral LK (vision: 20/25) (b) After central LK (vision: CF due to glaucoma) Figure 3: Patient S with poor visual outcome (a) Sectoral LK with graft infection (b) Infected SKP (Candida) (eventually underwent evisceration)

9. Discussion  The role of surgery in the management of Mooren’s ulcer has been described, though no definite trends are apparent due to several reasons, including Rarity of the disease Wide variety of surgical techniques employed Paucity on literature on the subject, with available reports being limited by small numbers  Various surgical options have been described for therapeutic and tectonic purposes, including 2-6 Superficial lamellar keratectomy Keratoepithelioplasty Lamellar keratoplasty Penetrating keratoplasty

10. Discussion  Our study demonstrates that keratoplasty with systemic immunosuppression restored globe integrity with good to fair visual retention in about 85% of eyes with advanced Mooren’s ulceration.  Poor outcome was related to recurrent melts from graft infection or relapse of Mooren’s ulceration Repeat keratoplasty appeared to carry a poorer prognosis Advanced glaucoma is another serious problem

11. Conclusion  Therapeutic keratoplasty should be considered in advanced cases of Mooren’s ulceration when conservative treatment fails to prevent disease progression.

12. References 1) Sangwan VS, Zafirakis P, Foster CS. Mooren's ulcer: current concepts in management. Indian J Ophthalmol 1997;45(1):7-17. 2) Brown SI, Mondino BJ. Therapy of Mooren's ulcer. Am J Ophthalmol 1984;98(1):1-6. 3) Martin NF, Stark WJ, Maumenee AE. Treatment of Mooren's and Mooren's-like ulcer by lamellar keratectomy: report of six eyes and literature review. Ophthalmic Surg 1987;18(8):564-9. 4) Kinoshita S, Ohashi Y, Ohji M, Manabe R. Long-term results of keratoepithelioplasty in Mooren's ulcer. Ophthalmology 1991;98(4):438-45. 5) Agrawal V, Kumar A, Sangwan V, Rao GN. Cyanoacrylate adhesive with conjunctival resection and superficial keratectomy in Mooren's ulcer. Indian J Ophthalmol 1996;44(1):23-7. 6) Du Nian Z, Chen Jia Q, Gong Xian M, Xu Hong T. [Mooren's ulcer treated by lamellar keratoplasty (author's transl)]. Nippon Ganka Gakkai Zasshi 1979;83(10):1855-60.