Evaluation of a severity-based surgical strategy for refractory Mooren’s ulcer: A retrospective series with long-term follow-up

Objective To evaluate the clinical outcomes of a Severity-Based Surgical Algorithm for treating refractory Mooren’s ulcer. Methods We retrospectively reviewed consecutive patients with Mooren’s ulcer who underwent surgical intervention between February 2016 and January 2024 after failing medical therapy. A predefined severity-based surgical algorithm was applied: amniotic membrane transplantation (AMT) for ulcers involving <2/3 stromal thickness; lamellar keratoplasty (LK) for ulcers ≥2/3 thickness or perforations ≤4 mm; and penetrating keratoplasty (PK) for perforations >4 mm or technical infeasibility of LK. All patients received postoperative systemic and local immunosuppression. Primary outcomes included primary healing, changes in best-corrected visual acuity (BCVA), recurrence, and anatomical success. Results The cohort comprised 24 patients (24 eyes) with a mean follow-up of 30 months (range 12–84). Seven eyes underwent AMT, 15 LK, and 2 PK. Primary healing rates were 100% for AMT and PK, and 93.3% for LK (overall 95.8%). Although BCVA improved or stabilized in 71.4% of AMT and 86.7% of LK eyes, functional acuity (BCVA ≥ 0.3) was achieved in 71.4% (5/7) of the AMT group compared to only 13.3% (2/15) of the LK group. Conversely, PK outcomes were poor (HM to NLP). Recurrence rates were 28.6% (2/7) for AMT, 64.3% (9/14) for LK, and 100% (2/2) for PK. Kaplan-Meier analysis showed a median recurrence-free survival of 36 months for the LK group. Crucially, final anatomical success was achieved in 85.7% of AMT, 93.3% of LK, and 50.0% of PK eyes, resulting in an overall globe preservation rate of 87.5% (21/24). Conclusion A severity-graded surgical approach effectively preserves globe integrity in refractory Mooren’s ulcer. While AMT provides excellent outcomes for less-severe cases, cases requiring keratoplasty demonstrate more aggressive disease biology with higher recurrence risks. Therefore, vigilant long-term follow-up and sustained immunomodulation are mandatory for severe cases.