Surgical ManeuversPublication Exclusive

Second-stage operation of Mooren’s ulcer

This step consists of anterior lamellar keratoplasty and cryopreserved human amniotic membrane transplantation.

Mooren’s ulcer is a clinical entity that results in peripheral ulcerative keratitis and corneal ulceration. A subset of these patients requires surgical intervention to stabilize the cornea and maintain ocular integrity. Although both cell-mediated and humoral immune mechanisms have been implicated in the possible pathogenic pathway leading to peripheral corneal melt and corneal ulceration, the exact etiology is yet to be fully understood.

The clinical signs and symptoms and the types of Mooren’s ulcer were described in a previous Ocular Surgery News article about the first stage of surgery in this patient (Oct. 10, 2015, page 6).

In this column, I describe the second-stage surgery in Mooren’s ulcer, namely anterior lamellar keratoplasty and cryopreserved human amniotic membrane transplantation. This surgical procedure is performed when the eye is much quieter with significantly less inflammation and stabilization of the previous descemetocele and corneal ulceration following the first-stage amniotic membrane transplantation.

Figure 1. Top row: The area of peripheral corneal melt in a patient with Mooren’s ulcer is demarcated using a sterile marking pen. This is the second stage of surgery when the eye is much quieter with less inflammation following the initial multi-layered amniotic membrane transplantation. Bottom row: Using a straight crescent blade, the borders around the area of corneal melt and thinning are delineated, and this area is de-epithelialized.

Images: John T

Figure 2. The donor cornea is mounted within an artificial anterior chamber, and the intra-chamber space is pressurized. Using a microkeratome, a lamellar corneal donor disc is created.
Figure 3. Top row: The donor lamellar disc is de-epithelialized. Bottom row: The distal edge of the donor disc is aligned with the peripheral ulcerative margin, and the area to be prepared for grafting is demarcated using the sterile marking pen.
Figure 4. The semilunar-shaped donor lamellar disc is surgically created to custom fit the region of peripheral ulceration.
Figure 5. The donor lamellar graft is flipped on its epithelial surface, and the stroma is fashioned to appropriately fit the ulcerative corneal gutter without any edge lift.
Figure 6. Tisseel fibrin glue is applied to the ulcerative recipient corneal bed and the stromal surface of the donor semilunar lamellar graft. Arrows point to the donor semilunar lamellar graft.
Figure 7. Top row: A muscle hook is used to iron the lamellar donor graft surface to facilitate uniform attachment of the donor graft to the recipient corneal bed. Bottom row: Cryopreserved human amniotic membrane is attached to the recipient cornea as an overlay graft.
Figure 8. Tisseel fibrin glue is used to attach the onlay cryopreserved human amniotic membrane to the corneal surface. Bottom right: Intraoperative slit lamp is used to ensure that the transplanted surgically created corneal surface is uniform over the donor recipient corneal surface, without any step, edge lift or irregularities.
Figure 9. Completed view of semilunar anterior lamellar keratoplasty and onlay human cryopreserved amniotic membrane, showing restoration of the corneal defect and a smooth, even ocular surface, which will facilitate uniform tear film spread and provide improved patient comfort and augment corneal remodeling and healing.

The technique

The anesthesia may be monitored anesthesia care or general anesthesia, depending on surgeon and patient preference. This second-stage operation consists of first performing semilunar anterior lamellar keratoplasty, followed by amniotic membrane transplantation.

The area of peripheral corneal melt in this case of Mooren’s corneal ulcer is demarcated using a sterile marking pen (Figure 1). Using a straight crescent blade, the borders around the area of corneal melt and thinning are delineated (Figure 1). The epithelium is then removed in this region by gentle mechanical debridement. Next, the donor cornea is mounted within an artificial anterior chamber, and the intra-chamber space is pressurized (Figure 2). Using an automated microkeratome, a donor lamellar corneal disc is created (Figure 2). The donor lamellar corneal disc is then de-epithelialized using sterile Weck-Cel spears (Figure 3). This donor corneal disc is placed over the recipient corneal surface, and the distal edge of the donor disc is aligned with the recipient peripheral ulcerative margin (Figure 3). The area to be prepared for grafting is demarcated using the sterile marking pen (Figure 3). The donor graft margins are fashioned to be slightly larger than the area of recipient corneal ulceration. The semilunar-shaped donor lamellar disc is surgically created to custom fit the region of peripheral ulceration (Figure 4). The donor disc edges on the stromal side are beveled, and excess corneal stromal tissue is debulked by sharp dissection to facilitate this optimal fit of the donor corneal graft to the recipient corneal bed.

The lamellar graft is attached with a single 10-0 nylon suture and flipped on its epithelial surface, and the stroma is further fashioned as needed to appropriately fit the ulcerative corneal gutter without any edge lift (Figure 5). Tisseel Lyo (Baxter) is applied to the surgically prepared ulcerative recipient corneal bed and the stromal surface of the donor semilunar lamellar graft (Figure 6). A muscle hook is used to iron the lamellar donor graft surface to facilitate uniform attachment of the donor graft to the recipient corneal bed (Figure 7). Cryopreserved human amniotic membrane (Bio-Tissue) is attached to the recipient cornea as an overlay graft using interrupted 10-0 nylon sutures (Figure 7). Tisseel Lyo is used again to attach the onlay cryopreserved human amniotic membrane to the corneal surface overlying the lamellar keratoplasty (Figure 8). Intraoperative biomicroscopy is used to ensure that the transplanted surgically created corneal surface is uniform over the donor-recipient corneal surface, without any step, edge lift or irregularities (Figure 8).

A completed view of the semilunar anterior lamellar keratoplasty and the onlay human cryopreserved amniotic membrane, showing restoration of the corneal defect and a smooth, even ocular surface that will facilitate uniform tear film spread and provide improved patient comfort and augment corneal remodeling and healing, is shown in Figure 9.

Disclosure: John reports he is a consultant for, is on the speakers bureau of and has a stock interest in Bio-Tissue.

Mooren’s ulcer is a clinical entity that results in peripheral ulcerative keratitis and corneal ulceration. A subset of these patients requires surgical intervention to stabilize the cornea and maintain ocular integrity. Although both cell-mediated and humoral immune mechanisms have been implicated in the possible pathogenic pathway leading to peripheral corneal melt and corneal ulceration, the exact etiology is yet to be fully understood.

The clinical signs and symptoms and the types of Mooren’s ulcer were described in a previous Ocular Surgery News article about the first stage of surgery in this patient (Oct. 10, 2015, page 6).

In this column, I describe the second-stage surgery in Mooren’s ulcer, namely anterior lamellar keratoplasty and cryopreserved human amniotic membrane transplantation. This surgical procedure is performed when the eye is much quieter with significantly less inflammation and stabilization of the previous descemetocele and corneal ulceration following the first-stage amniotic membrane transplantation.

Figure 1. Top row: The area of peripheral corneal melt in a patient with Mooren’s ulcer is demarcated using a sterile marking pen. This is the second stage of surgery when the eye is much quieter with less inflammation following the initial multi-layered amniotic membrane transplantation. Bottom row: Using a straight crescent blade, the borders around the area of corneal melt and thinning are delineated, and this area is de-epithelialized.

Images: John T

Figure 2. The donor cornea is mounted within an artificial anterior chamber, and the intra-chamber space is pressurized. Using a microkeratome, a lamellar corneal donor disc is created.
Figure 3. Top row: The donor lamellar disc is de-epithelialized. Bottom row: The distal edge of the donor disc is aligned with the peripheral ulcerative margin, and the area to be prepared for grafting is demarcated using the sterile marking pen.
Figure 4. The semilunar-shaped donor lamellar disc is surgically created to custom fit the region of peripheral ulceration.
Figure 5. The donor lamellar graft is flipped on its epithelial surface, and the stroma is fashioned to appropriately fit the ulcerative corneal gutter without any edge lift.
Figure 6. Tisseel fibrin glue is applied to the ulcerative recipient corneal bed and the stromal surface of the donor semilunar lamellar graft. Arrows point to the donor semilunar lamellar graft.
Figure 7. Top row: A muscle hook is used to iron the lamellar donor graft surface to facilitate uniform attachment of the donor graft to the recipient corneal bed. Bottom row: Cryopreserved human amniotic membrane is attached to the recipient cornea as an overlay graft.
Figure 8. Tisseel fibrin glue is used to attach the onlay cryopreserved human amniotic membrane to the corneal surface. Bottom right: Intraoperative slit lamp is used to ensure that the transplanted surgically created corneal surface is uniform over the donor recipient corneal surface, without any step, edge lift or irregularities.
Figure 9. Completed view of semilunar anterior lamellar keratoplasty and onlay human cryopreserved amniotic membrane, showing restoration of the corneal defect and a smooth, even ocular surface, which will facilitate uniform tear film spread and provide improved patient comfort and augment corneal remodeling and healing.

The technique

The anesthesia may be monitored anesthesia care or general anesthesia, depending on surgeon and patient preference. This second-stage operation consists of first performing semilunar anterior lamellar keratoplasty, followed by amniotic membrane transplantation.

The area of peripheral corneal melt in this case of Mooren’s corneal ulcer is demarcated using a sterile marking pen (Figure 1). Using a straight crescent blade, the borders around the area of corneal melt and thinning are delineated (Figure 1). The epithelium is then removed in this region by gentle mechanical debridement. Next, the donor cornea is mounted within an artificial anterior chamber, and the intra-chamber space is pressurized (Figure 2). Using an automated microkeratome, a donor lamellar corneal disc is created (Figure 2). The donor lamellar corneal disc is then de-epithelialized using sterile Weck-Cel spears (Figure 3). This donor corneal disc is placed over the recipient corneal surface, and the distal edge of the donor disc is aligned with the recipient peripheral ulcerative margin (Figure 3). The area to be prepared for grafting is demarcated using the sterile marking pen (Figure 3). The donor graft margins are fashioned to be slightly larger than the area of recipient corneal ulceration. The semilunar-shaped donor lamellar disc is surgically created to custom fit the region of peripheral ulceration (Figure 4). The donor disc edges on the stromal side are beveled, and excess corneal stromal tissue is debulked by sharp dissection to facilitate this optimal fit of the donor corneal graft to the recipient corneal bed.

The lamellar graft is attached with a single 10-0 nylon suture and flipped on its epithelial surface, and the stroma is further fashioned as needed to appropriately fit the ulcerative corneal gutter without any edge lift (Figure 5). Tisseel Lyo (Baxter) is applied to the surgically prepared ulcerative recipient corneal bed and the stromal surface of the donor semilunar lamellar graft (Figure 6). A muscle hook is used to iron the lamellar donor graft surface to facilitate uniform attachment of the donor graft to the recipient corneal bed (Figure 7). Cryopreserved human amniotic membrane (Bio-Tissue) is attached to the recipient cornea as an overlay graft using interrupted 10-0 nylon sutures (Figure 7). Tisseel Lyo is used again to attach the onlay cryopreserved human amniotic membrane to the corneal surface overlying the lamellar keratoplasty (Figure 8). Intraoperative biomicroscopy is used to ensure that the transplanted surgically created corneal surface is uniform over the donor-recipient corneal surface, without any step, edge lift or irregularities (Figure 8).

A completed view of the semilunar anterior lamellar keratoplasty and the onlay human cryopreserved amniotic membrane, showing restoration of the corneal defect and a smooth, even ocular surface that will facilitate uniform tear film spread and provide improved patient comfort and augment corneal remodeling and healing, is shown in Figure 9.

Disclosure: John reports he is a consultant for, is on the speakers bureau of and has a stock interest in Bio-Tissue.