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Title: PRESENTATION, MANAGEMENT, AND OUTCOMES OF MOOREN’S ULCER IN AFRICA AND ASIA: A SYSTEMATIC REVIEW AND CASE SERIES(2018)

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Background: Mooren’s Ulcer can be a devastating disease and while studies have described different types of this ulceration, there seems to be a different and more aggressive type of disease described in Africa, affecting a younger generation. Despite this being the case, there is little data available on this disease and treatment is often difficult with no Randomized Clinical Trials (RCTs) to prove the efficacy of these treatments. We aimed therefore, to review and summarize evidence on the presentation, interventions, and outcome of Mooren’s Ulcer of studies done in Africa and Asia, using a systematic review, as well as describe the presentation, management, and outcomes of these patients at REC/MURHEC. Methods: We conducted a mixed methods study by doing both a systematic review and a case series. The systematic review followed the Cochrane Collaboration Diagnostic Test Accuracy Working Group and PRISMA Statement guidelines. Our electronic search with the key words Moorens Ulcer, Peripheral Keratitis, Marginal Keratitis, and Peripheral Ulcerative Keratitis run from 02/09/2016 to 30/12/2017 on PubMed, Medline, Embase and Google Scholar databases. For included papers, we collected data on patient presentation, patient treatment, and outcomes. We used the SIGN 50 criteria for level of evidence for each study. We analyzed and reported on the data by summary descriptive tables. For the case series, we enrolled a total of 8 patients over 3 months and followed them up over an additional 3 months. Systemic investigations as well as cornea microbiology testing were done for each participant. We collected data on their history, presentation, management, clinical course, and outcomes of the disease. The data are presented as well as photographic evidence. RESULTS: For the systematic review, we included 12 studies (4 in Africa, 8 in Asia) with a total of 1,041 participants. Many of these studies had missing data on key aspects of diagnosis, severity, and outcome of the treatment, and the strength of evidence was generally weak. Sample sizes ranged from 5-550, mean age from 13-65, proportion of males from 37-83%, presenting visual acuity 0.1-1.0 LogMAR, bilaterality from 0-46% and co-infection rates from 0-16%. Clinical diagnosis of Mooren’s was used in 7/12 studies, and step-wise treatment protocol in 9/12 studies. Outcomes were varied and final visual acuity 0.3-0.8 LogMAR. For the case series, 8 patients were enrolled. The median age was 26 years (IQR 22-27.5), with 6 males and 2 females enrolled. All the systemic investigations were normal or negative but corneal microbiology revealed 3 fungal co-infections of the ulceration. Three of the patients had history of trauma. The earliest presenting time was 1 month after start of symptoms and all the patients had used Traditional Eye Medication (TEM). Another 3 patients presented with advanced, perforated ulcers. The median presenting visual acuity was 0.75 LogMAR, with final median visual acuity being 0.70 LogMAR. There were no eye removals. CONCLUSION: The systematic review shows that Mooren’s Ulcer indeed affects a younger population in Africa; however, all the included African studies were carried out only in West Africa. The information from the studies was varied with non-reporting on key factors, from many studies. The case series shows that the use of TEM is common and that patients present late with advanced ulcers making treatment that much more difficult. A multi-center Randomized Controlled Trial would be key in providing evidence for better management of this condition particularly in resource limited settings.

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