Immunohistochemistry of Terrien's and Mooren's corneal degeneration

Descemet stripping endothelial keratoplasty after cytomegalovirus corneal endotheliitis and immunosuppression for Mooren's ulcer

Purpose

The aim of this report was to describe a case of cataract surgery and Descemet stripping automated endothelial keratoplasty (DSAEK) after cytomegalovirus (CMV) corneal endotheliitis and bullous keratopathy (BK) following immunosuppressive treatment for Mooren's ulcer.

Observations

A 64-year-old man was referred to our hospital because of peripheral ulcerative keratitis in his left eye. He had a history of trabeculectomy for open angle glaucoma in his left eye. He was diagnosed with Mooren's ulcer and treated with topical betamethasone and tacrolimus with systemic cyclosporine. The corneal ulcer improved, but the peripheral cornea thinned from 6 to 12 and 0-2 o'clock. Five months later, cells were observed in the left anterior chamber, and real-time polymerase chain reaction examination of the aqueous humor showed CMV-DNA-positive results. The patient was diagnosed with CMV corneal endotheliitis, and oral ganciclovir was administered. Fifteen months after the initial presentation, BK appeared with decreased vision to 20 cm/n. d. After confirmation of negative CMV-DNA in the aqueous humor, DSAEK was performed following cataract surgery. The postoperative visual acuity recovered to 0.3. Mooren's ulcer exacerbation and CMV corneal endotheliitis did not recur postoperatively.

Conclusions and Importance

This is the first report of a case in which a patient with Mooren's ulcer developed BK due to CMV corneal endotheliitis and required DSAEK. Cataract surgery and DSAEK could be performed without issue by creating the main wound and side ports in a manner that avoids the thinned parts of the cornea.

Diagnostic Criteria for Terrien Marginal Degeneration: Nordic Terrien Degeneration Study

PURPOSE

To refine the diagnostic criteria for Terrien marginal degeneration (TMD) based on experience in 3 Nordic countries.

METHODS

This is a retrospective, multicenter, hospital-based cross-sectional study of 49 eyes of 29 white patients in tertiary referral centers in Finland, Sweden, and Denmark from 1998 to January 2018. The median follow-up was 3 years. Symptoms, best corrected visual acuity, astigmatism, corneal thickness, curvature and cavities, stage, and progression were analyzed.

RESULTS

TMD was diagnosed equally likely between 15 and 86 years of age (median, 47 years). Twenty patients (69%) had bilateral disease, and 62% were men. Seventeen patients (59%) had symptoms including blurred vision and ocular surface disease symptoms without inflammatory signs. Eight patients (28%) had slightly reduced corneal sensitivity. Median best corrected visual acuity was 20/25 (range, 20/16-20/200) and astigmatism was 2.6 diopters (D) (range, 0-10) with a mean progression of 0.41 D per year (range, 0-5.4). Age and astigmatism were not correlated. All eyes had peripheral vascularization, lipid deposits, and hyperreflectivity throughout thinned peripheral stroma and its anterior edge. The thinning progressed in 15 patients (52%). Of 26 patients, 8 (31%) had single or confluent paralimbal intrastromal cavities, most commonly superiorly. By Süveges classification, the stage was 2 (92%) or 3 (8%). Minimum corneal thickness and corneal curvature were loosely associated, leading to different stages in Wang classification in 34 eyes (69%).

CONCLUSIONS

TMD is defined by peripheral corneal thinning, superficial neovascularization, lipid deposition at the leading edge, absence of ulceration and inflammation, and frequently cavitation. The most sensitive way to follow its progression is anterior segment optical coherence tomography.

[Mooren's ulcer]

The article reviews available data on Mooren's ulcer - a rare disease of, supposedly, autoimmune origin that manifests as peripheral ulceration of the cornea and poses a risk of its perforation. The variability of clinical presentation and course of the disease often leads to misdiagnosis and inadequate treatment. The present review focuses on specific signs characteristic of the disease and the most effective methods of its treatment.

Spontaneous corneal perforation in Terrien's marginal degeneration in childhood: A case report

RATIONALE

Terrien's marginal corneal degeneration (TMD) is characterized by progressive peripheral corneal thinning. It appears primarily above the age of 40 years and is rare at younger ages. Spontaneous corneal perforation in TMD is a rare, but serious complication that may occur in childhood.

PATIENT CONCERNS

This review presents the case of a 16-year-old girl presented with blurred vision in the right eye on awakening in the morning. Slit-lamp examination revealed superior corneal thinning with a corneal perforation.

DIAGNOSES

The best-corrected visual acuity (BCVA) was 20/50 in the right eye and 20/20 in the left eye. Intraocular pressures were 5 and 18 mm Hg in the right and left eyes, respectively, measured using a noncontact tonometer. Slit-lamp examination revealed superior corneal thinning with superficial pannus. A 1-mm corneal perforation was observed at the 11 o'clock position. The anterior chamber of the right eye was flat and the Seidel test result was positive. The left eye showed no apparent abnormality on slit-lamp examination. Corneal topography showed 4.3 D of against-the-rule astigmatism, and anterior segment optical coherence tomography revealed superior corneal thinning. We diagnosed it as childhood onset TMD.

INTERVENTIONS

Multilayered amniotic membrane transplantation was performed over the perforation site and a bandage contact lens was placed.

OUTCOMES

At 1 week postoperatively, the BCVA of the right eye improved to 20/32, the amniotic membrane graft was well-attached, and the anterior chamber remained deep. At 2 months postoperatively, the BCVA was 20/25 and the anterior chamber depth was maintained.

LESSONS

Spontaneous corneal perforation due to TMD is rare, but may occur in childhood. The possibility of corneal perforation should be considered even in childhood and good surgical results can be obtained with amniotic membrane transplantation.

Patch Graft for Corneal Perforation Following Trivial Trauma in Bilateral Terrien's Marginal Degeneration

A young female presented with blurred vision in the left eye after she rubbed her eye. On examination of both eyes, she had 360° thinning adjacent to the limbus, lipid deposition and superficial vascularization with a perforation in the left eye. The patient was diagnosed with bilateral Terrien's marginal degeneration (TMD) with perforation. Corneal topography of the right eye revealed high oblique astigmatism confirming the diagnosis. A peripheral patch graft was performed for the left eye. At 18 months postoperatively, the best-corrected visual acuity was 20/20 in both eyes. The graft was clear. Topography of right eye was stable, and the left eye had oblique astigmatism. Bilateral advanced TMD in a young patient presenting with corneal perforation following trivial trauma is extremely uncommon. Patch graft may be an option for restoring the globe integrity in such cases. Regular follow-up is necessary as the condition progresses slowly.

Clinical correlates of common corneal neovascular diseases: a literature review

A large subset of corneal pathologies involves the formation of new blood and lymph vessels (neovascularization), leading to compromised visual acuity. This article aims to review the clinical causes and presentations of corneal neovascularization (CNV) by examining the mechanisms behind common CNV-related corneal pathologies, with a particular focus on herpes simplex stromal keratitis, contact lenses-induced keratitis and CNV secondary to keratoplasty. Moreover, we reviewed CNV in the context of different types of corneal transplantation and keratoprosthesis, and summarized the most relevant treatments available so far.

Amniotic membrane transplantation ineffective as additional therapy in patients with aggressive Mooren's ulcer

Background

Mooren’s ulcer is a severe ulcerative inflammation of the cornea. The exact pathogenesis remains unclear. Therefore many therapies of Mooren’s ulcer are recommended in literature. To shed more light on the ongoing question of optimal treatment of severe progressive Mooren’s ulcer, we here report on a retrospective case series of patients treated with systemic immunosuppressive therapy and additional amniotic membrane transplantation.

Methods

Medical records from seven patients (eleven eyes), 4 male and 3 female, with severe progressive Mooren’s ulcer were analysed retrospectively. The mean follow up was 88.4 ± 80.8 months (range 12–232 month). A HLA-typing was performed in all patients. A systemic immunosuppressive therapy was administered in all patients. The amniotic membrane was transplanted after the base of the ulcer was resected.

Results

Multiple amniotic membrane transplantations were necessary in six patients. The visual outcome of all patients was poor. No patient achieved a visual acuity better than 20/630 Snellen chart. Five patients were positive for HLA-DQ2 and four patients were positive for HLA-DR17(3).

Conclusions

The aggressive and highly inflammatory form of Mooren’s ulcer is difficult to treat and the progression of the disease is hard to influence positively even under systemic immunosuppressive therapy. Therefore, the main intention of therapy is to achieve a stable epithelialized corneal surface without the risk of perforation. Amniotic membrane transplantation is not able to cure severe forms of Mooren’s ulcer. However it supports the immunosuppressive therapy in acute situations as in critical corneal thinning.

Corneal neovascularization: an anti-VEGF therapy review

Corneal neovascularization is a serious condition that can lead to a profound decline in vision. The abnormal vessels block light, cause corneal scarring, compromise visual acuity, and may lead to inflammation and edema. Corneal neovascularization occurs when the balance between angiogenic and antiangiogenic factors is tipped toward angiogenic molecules. Vascular endothelial growth factor (VEGF), one of the most important mediators of angiogenesis, is upregulated during neovascularization. In fact, anti-VEGF agents have efficacy in the treatment of neovascular age-related macular degeneration, diabetic retinopathy, macular edema, neovascular glaucoma, and other neovascular diseases. These same agents have great potential for the treatment of corneal neovascularization. We review some of the most promising anti-VEGF therapies, including bevacizumab, VEGF trap, siRNA, and tyrosine kinase inhibitors.

Update on pathologic diagnosis of corneal infections and inflammations

One of the most frequent types of corneal specimen that we received in our pathology laboratory is an excised corneal tissue following keratoplasty. Several of these cases are due to corneal infections or the sequelae, like corneal scar. Advances in the histological and molecular diagnosis of corneal infections and inflammations have resulted in rapid and accurate diagnosis of the infectious agent and in the overall understanding of the mechanisms in inflammatory diseases of the cornea. This review provides an update of histopathological findings in various corneal infections and inflammations.

Laser scanning in vivo confocal microscopy in a case of Terrien marginal degeneration

PURPOSE

To describe corneal microstructural modifications in an early case of Terrien marginal degeneration by means of laser scanning in vivo corneal confocal microscopy.

METHODS

A 20-year-old man affected by Terrien marginal degeneration in his right eye was examined with the Heidelberg Retina Tomograph 2 with a Rostock Cornea Module. The patient presented a corneal lesion with marked superior thinning and no clinical signs of inflammation. The left eye showed no clinical signs of degeneration.

RESULTS

The right eye showed irregular Bowman's membrane, amorphous-appearing substance co-localizing with lipid exudation, and needle-like hyperreflective material in the affected peripheral corneal region. Abnormally scarce and branched sub-basal plexus nerves as well as numerous activated keratocytes, sometimes organized in hyperreflective nests, were observed in the central cornea of the same eye. Although the left eye was clinically unaffected, activated keratocytes were detected in its anterior central stroma.

CONCLUSIONS

In vivo confocal microscopy supports the hypothesis of a mild inflammatory state with an atypical sub-basal nerve pattern in a patient affected by Terrien marginal degeneration. This new technique shows promise in studying this still elusive pathology.

Chronic hepatitis C virus infection is not associated with Mooren's ulcer

AIM

To investigate the association between chronic hepatitis C virus (HCV) infection and Mooren's ulcer.

METHODS

Eight patients from different parts of China who were diagnosed with Mooren's ulcer at the Zhongshan Ophthalmic Center, Guangzhou (China) were screened for chronic HCV infection. Mooren's ulcer was diagnosed by the typical ulcer morphology, detailed case history, physical examination, and comprehensive laboratory tests. All patients had serological screening for HCV infection.

RESULTS

Six male and two female patients were enrolled in the study. Their ages ranged from 31 to 65 years (mean 43.6+/-13.7). None of them was reported to have any clinical evidence of chronic HCV infection before enrolment and all were negative for HCV serology.

CONCLUSION

There was no association between chronic HCV infection and Mooren's ulcer in this limited case series study.

Terrien Marginal Degeneration Presenting With Spontaneous Corneal Perforation

PURPOSE

To report spontaneous corneal perforation as a presenting sign of unilateral Terrien marginal degeneration in a young adult.

METHODS

A 19-year-old woman presented with sudden loss of vision in her left eye of 1-day duration. Examination revealed superior corneal thinning with superficial vascularization and secondary lipid keratopathy. There was an area of corneal perforation at the 11 o'clock position, leading to a shallow anterior chamber, ocular hypotony, and a hypotonic maculopathy. The right eye was normal on biomicroscopy.

RESULTS

The area of perforation was confirmed by a positive Seidel test. A 22-mm-diameter bandage contact lens was fitted, which led to closure of the perforation and reformation of the anterior chamber. Orbscan corneal topography confirmed superior corneal thinning, 2.3 D of against-the-rule astigmatism, and 3.4 D of irregular astigmatism in the central 3-mm zone. Topography of the right showed no apparent abnormality.

CONCLUSION

Terrien marginal degeneration is an unusual cause for a spontaneous corneal perforation. Patients with this disorder should be warned about this possibility.

The involvement of multipotential progenitor cells in Mooren's ulcer

The aim of this study was to assess the involvement of multipotential progenitor cells in the pathogenesis of Mooren's ulcer using immunohistochemical staining techniques. Tissue specimens were collected from 3 Mooren's ulcer patients who underwent lamellar keratectomy. Immunohistochemical staining patterns were analyzed using antibodies: CD34, c-kit, STRO-1, CD45RO, VEGF and a-SMA. Strong positive CD34, c-kit and STRO-1 cells were revealed in Mooren's ulcer specimens, especially in the superficial stroma. A few weakly expressed CD34 stroma cells were seen in normal limbal cornea but no immunoreactivity for c-kit and STRO-1 could be found. CD45RO positive T cells were found to have infiltrated in Mooren's ulcer. The immunostaining pattern of VEGF and a- SMA was closely correlated with the degree of expression and the number of CD34 positive cells. Bone marrow-derived multipotential progenitor cells may be involved in the pathogenesis of Mooren's ulcer by synergizing with other factors to amplify autoimmune destructive reactions and to contribute to the regeneration process. Specific therapeutic strategies that target the role of these cells in the disease are warranted.

Microsurgical treatment of Mooren's corneal ulcer

This study evaluated the effect of microsurgery of lamellar keratoplasty (LKP) on Mooren's corneal ulcer. The surgical effect, postoperative astigmatism, postoperative vision, postoperative ulcer recurrence, and surgical complications of 2 groups of consecutive Mooren's ulcer inpatients treated respectively by non-microsurgery of LKP and microsurgery of LKP were analyzed. There were significant differences of the effect, postoperative astigmatism, postoperative vision, postoperative ulcer recurrence, and surgical complications between the 2 groups. The effect and postoperative vision of the microsurgery-treated group were better than those of the non-microsurgery-treated group. The postoperative astigmatism, postoperative ulcer recurrence, and surgical complications of the microsurgery-treated group were less than those of the non-microsurgery-treated group. Microsurgery of LKP of Mooren's corneal ulcer can greatly improve the cure rate of the disease and postoperative vision, and reduce surgical complication and postoperative ulcer recurrence.

[Severe Moorens ulcer: efficacy of monthly cyclophosphamide intravenous pulse treatment]

PURPOSE

Mooren's ulcer (MU) is a chronic peripheral corneal ulceration featuring conjunctival immunoglobulin deposits. It is considered as the result of a limbic immune process with hyperactivation of T and B lymphocytes. The etiology remains unknown. The response to topical steroid therapy and surgical procedures usually poor and the visual outcome can be devastating.

METHODS

Clinical follow-up of 3 patients who had rebel MU to conventional therapy, and were treated with 1g monthly intravenous cyclophosphamide.

RESULTS

First patient was a 24-years-old man who had MU in his left eye. The response to surgical procedure and intravenous steroid treatment was poor and corneal perforation occurred. The affected cornea healed after 9 months of Cy treatment. The second patient was a 50-years-old man who had MU in his left eye, which did not improved with lamellar keratoplasty and topical steroid therapy. Corneal healing was obtained after 20 months of Cy treatment. The third patient was a 70-years-old man who presented with a furrowed MU in his right eye which healed with conjunctival resection and 4 months of Cy perfusion. No adverse effects of Cy was noted as opposed to Cy given orally.

CONCLUSION

We report the effectiveness of 1g monthly intravenous cyclophosphamide (Cy) treatment in rebel MU. We suggest that immunosuppressive therapy using IV monthly Cy may be proposed in severe rebel MU.

Corneal neovascularization

Corneal neovascularization (NV) is a sight-threatening condition usually associated with inflammatory or infectious disorders of the ocular surface. It has been shown in the field of cancer angiogenesis research that a balance exists between angiogenic factors (such as fibroblast growth factor and vascular endothelial growth factor) and anti-angiogenic molecules (such as angiostatin, endostatin, or pigment epithelium derived factor) in the cornea. Several inflammatory, infectious, degenerative, and traumatic disorders are associated with corneal NV, in which the balance is tilted towards angiogenesis. The pathogenesis of corneal NV may be influenced by matrix metalloproteinases and other proteolytic enzymes. New medical and surgical treatments, including angiostatic steroids, nonsteroidal inflammatory agents, argon laser photocoagulation, and photodynamic therapy have been effective in animal models to inhibit corneal NV and transiently restore corneal "angiogenic privilege."

Mooren's ulcer in China: a study of clinical characteristics and treatment

AIMS

To investigate the clinical characteristics and compare the effects of several methods of treatment of Mooren's corneal ulcer.

METHODS

550 consecutive cases of Mooren's corneal ulcer were analysed in patients, including age, sex, laterality of eye, ulcer location, perforative rate, cure rate of surgeries, recurrent rate, the effects of conjunctiva excision, lamellar keratoplasty (LKP), and LKP plus 1% cyclosporin A eye drops.

RESULTS

The average age of onset was 48.4 years of age. The ratio of males to females was 1:0. 74. 165 (30%) cases had the disease bilaterally, of which 52 (31.5%) occurred in the young age group and 113 (68.5%) in the old age group. Ulcers of 501 eyes (70.1%) were located at the limbus of the palpebral fissure. The perforation rate was 13.3%, with perforation of 41 eyes (43.2%) occurring in the young age group and 54 (56.8%) in the old age group. Postoperative recurrence rate was 25.6%. The cure rate of the first procedure of LKP plus 1% cyclosporin A eye drops was 73.7%. The final cure rate was 95.6%, and the postoperative preservation rate of the eye globe was 99.7%.

CONCLUSION

This primary study provided the clinical characteristics of patients with Mooren's corneal ulcer in China. LKP plus 1% cyclosporin A eye drops was an effective treatment.