Penetrating keratoplasty and glaucoma valve surgery in recurrent Mooren's disease: A multidisciplinary approach

INTRODUCTION AND IMPORTANCE: The case report highlights the challenges in managing recurrent Mooren's ulcer, a rare and severe form of peripheral ulcerative keratitis. CASE PRESENTATION: A 49-year-old male, with bilateral Mooren's disease who underwent multiple surgical interventions for visual rehabilitation but developed disease recurrence in the left eye despite being on systemic and topical immunosuppression. The authors report successful long-term visual rehabilitation following a large-graft penetrating keratoplasty and Ahmed glaucoma valve implantation performed under immunosuppressive cover after adequate control of inflammation with intravenous Rituximab. CLINICAL DISCUSSION: We discuss the traditionally poor survival of penetrating keratoplasty in refractory Mooren's disease due to the recurrence of the disease in the graft. Occurrence of secondary glaucoma is commonly seen in these eyes, which often requires combined filtration surgery and medical management. The first and second line systemic immunosuppression may be insufficient in adequately controlling the disease, and that intravenous monoclonal antibodies, such as Rituximab, may be a promising treatment modality in refractory Mooren's disease prior to embarking on any surgical intervention. CONCLUSION: Overall, the case report highlights the importance of adequate control of inflammation and the use of immunosuppressive cover in achieving successful outcomes of PK and AGV surgery in Mooren's ulcer. The authors suggest that intravenous Rituximab may be a valuable addition to the management of refractory Mooren's disease, particularly prior to surgical intervention. However, as with any case report, the findings should be interpreted with caution and further research is needed to validate the efficacy of this treatment modality.