Hookworm Infestation as a Risk Factor for Mooren’s Ulcer in South India

doi:10.1016/j.ophtha.2006.08.014

Ophthalmology

Volume 114, Issue 3, March 2007, Pages 450-453

https://doi.org/10.1016/j.ophtha.2006.08.014 Get rights and content

Objective

To investigate the association between Mooren’s ulcer and intestinal hookworm infestation in South India.

Design

Prospective observational case–control study.

Participants

Fifteen patients with Mooren’s ulcer and 30 age- and gender-matched controls seen at Aravind Eye Hospital.

Methods

Stool samples from the Mooren’s ulcer patients and controls were collected and analyzed for presence of hookworm infestation.

Main Outcome Measure

Prevalence of hookworm infestation in Mooren’s ulcer patients and controls.

Results

There was a statistically significant correlation between intestinal hookworm infestation and the occurrence of Mooren’s ulcer (P = 0.009). Retrospective exploratory subgroup analyses suggested that the correlation between intestinal hookworm infestation and the occurrence of Mooren’s ulcer in men (P<0.0001) was stronger than the correlation in women, with no statistically significant difference being observed in the prevalence of hookworm infestation between women with Mooren’s ulcer and female control subjects (P>0.99). Similarly, when both the Mooren’s ulcer and the control subject groups were analyzed retrospectively by age > 50 years or age < 50, subjects with an age over 50 demonstrated a stronger correlation between hookworm infestation and Mooren’s ulcer than controls (P = 0.017), whereas there was no statistically significant difference in the prevalence of hookworm infection between Mooren’s ulcer subjects and control subjects ≤ 50 (P = 0.31).

Conclusion

Intestinal hookworm infestation appears to be associated with the development of Mooren’s ulcer in South India. Although the power of our retrospective exploratory subgroup analyses was limited by multiple testing and small sample sizes, these data suggest further that the correlation between intestinal hookworm infestation and the development of Mooren’s ulcer may be greatest in male patients with more advanced age.

Section snippets

Materials and Methods

Institutional review board approval was obtained. Information was gathered from 2 groups of subjects seen at the Aravind Eye Hospital in Madurai, India. The first group consisted of 15 subjects with the clinical diagnosis of Mooren’s ulcer who were recruited sequentially from the hospital’s cornea clinic. None of the subjects had a history of corneal trauma or infection, and 3 of the subjects had a history of cataract extraction in the affected eye. Mooren’s ulcer was defined as an idiopathic

Results

The demographic characteristics of the cases and controls and results of the various analyses are displayed in Table 1, Table 2, Table 3, Table 4, Table 5. There was no significant difference in the age distribution of cases versus controls (P = 0.58). Specifically, the mean and median ages of the subjects in the Mooren’s ulcer group were 49.7 and 50 years, respectively, with a range of 15 to 80, whereas the mean and median ages of the control group were 53.2 and 55, respectively, with a range

Discussion

We conducted a prospective observational case–control study to investigate the prevalence of intestinal hookworm infestation in patients with Mooren’s ulcer versus age- and gender-matched control subjects. Our data showed a strong association between intestinal hookworm infestation and Mooren’s ulcer in patients in South India. Although sample sizes and power were limited, retrospective exploratory subgroup analyses suggested further that the risk of developing Mooren’s ulcer appeared to depend

References (24)

J.D. Gottsch et al.
Mooren’s ulcer and evidence of stromal graft rejection after penetrating keratoplasty
Am J Ophthalmol
(1992)
H.G. Scheie et al.
Mooren’s-like ulcer in a corneal graft
Am J Ophthalmol
(1957)
J.J. Arentsen et al.
Marginal ulceration after intracapsular cataract extraction
Am J Ophthalmol
(1976)
S.M. Salamon et al.
Peripheral corneal ulcers, conjunctival ulcers, and scleritis after cataract surgery
Am J Ophthalmol
(1982)
B.J. Mondino et al.
Mooren’s ulcer after penetrating keratoplasty
Am J Ophthalmol
(1987)
M.E. Zegans et al.
Mooren ulcer in South India: serology and clinical risk factors
Am J Ophthalmol
(1999)
E.T. Kuriakose
Mooren’s ulcer: etiology and treatment
Am J Ophthalmol
(1963)
J.D. Gottsch et al.
Cytokine-induced calgranulin C expression in keratocytes
Clin Immunol
(1999)
W. Bowman
The parts concerned in the operations of the eye
Trans Ophthalmol Soc U K
(1902)
A. Mooren

H.C. Joondeph et al.

Mooren’s ulcer: two cases occurring after cataract extraction and treated with hydrophilic lens

Ann Ophthalmol

(1976)

H.J. Trojan

Aetiology and therapy of Mooren’s ulcer

Klin Monatsbl Augenheilkd

(1979)

Cited by (17)

Peripheral ulcerative keratitis
2021, Survey of Ophthalmology
Peripheral ulcerative keratitis (PUK) is an inflammatory condition of the peripheral cornea with hallmark features of epithelial defects and stromal destruction as a result of a complex interplay of factors including host autoimmunity and the peculiar anatomic and physiologic features of the peripheral cornea and environmental factors. PUK may be the result of local or systemic causes and infectious or noninfectious causes. Arriving at a specific etiological diagnosis requires a meticulous clinical workup that may include a battery of laboratory and radiological investigations. Management by a team of internists or rheumatologists and ophthalmologists and judicious use of immunosuppressive agents may yield favorable results minimizing adverse effects. We review current clinical knowledge on the diagnosis and management of PUK.
Case of bilateral Mooren's ulcers following filtering surgery using EX-PRESS glaucoma filtering devices
2020, American Journal of Ophthalmology Case Reports
Citation Excerpt :
Mooren's ulcer is believed to be caused by an autoimmune mechanism15 with both humoral- and cell-mediated autoimmune phenomena associated with it.2,10,11,15–19 The triggers for the hyperactive immune reactions might be trauma, surgery, and systemic or local infections.2–11 Gottsch et al. suggested that prior corneal surgery may play a role in the pathogenesis of Mooren's ulcer.10
To report our findings in a case of bilateral Mooren's ulcer that developed after filtering surgeries using the EX-PRESS glaucoma filtering device (EX-PRESS surgery).
A 71-year-old Japanese man with primary open angle glaucoma underwent EX-PRESS surgery first in his left eye and 1 month later in his right eye. He developed Mooren's ulcer in his right eye at 7 months and in his left eye at 10 months after the initial EX-PRESS surgery. Systemic examinations showed no collagen vascular disease, and he did not have a history of bacterial or viral infections. He was not allergic to metallic materials. Before the EX-PRESS surgery, he had underdone cataract surgery combined with trabeculotomy in both eyes, and a reoperation of trabeculotomy in his left eye. He had not developed Mooren's ulcer after these surgeries. The Mooren's ulcer after the EX-PRESS surgery was treated with oral prednisolone (30 mg tapering) in combination with topical 0.1% betamethasone sodium. The ulcers were responsive and healed well in three months.
The EX-PRESS devices were most likely the cause of the Mooren's ulcers considering that they were located close to the site of EX-PRESS insertion and no peripheral corneal ulcer developed after prior intraocular surgeries.
Clinical course and outcomes in patients with Mooren ulcer who had cataract surgery
2017, Journal of Cataract and Refractive Surgery
Citation Excerpt :
The demographics vary in different parts of the world. In the southern part of India, studies have shown male preponderance with an average age of presentation between 50 and 65 years.8,12–14 The sex and age distribution in our patients were similar.
To report outcomes of cataract surgery in patients with Mooren ulcer.
L.V. Prasad Eye Institute, Hyderabad, India.
Retrospective case series.
The medical records of patients with Mooren ulcer who had cataract surgery between 2000 and 2015 were assessed. The main outcome measures were the role of preoperative immunosuppression and disease inactivity, cataract surgery safety, visual outcomes, and postoperative ulcer recurrence.
Of 22 patients (26 eyes), the mean corneal ulceration was 6.8 clock hours ± 2.9 (SD). Corticosteroids were the most commonly used (84.6% of the 26 eyes) preoperative immunosuppression agents and 38.5% of the 26 eyes were under maintenance immunosuppression. The median disease inactivity before surgery was 7 months. Cataract surgery was extracapsular in 10 patients, small incision in 3 patients, and phacoemulsification in 13 patients. Twenty-two eyes had scleral incisions. The median follow-up was 6 months (interquartile range, 10 months). The median corrected distance visual acuity (CDVA) improved from 1.48 logarithm of minimum angle of resolution (logMAR) before surgery to 0.30 and 0.35 logMAR at 1 month and at the last follow-up after surgery, respectively (P ≤ .0001). Mooren ulcer recurred in 5 eyes between 3 months and 7 years after surgery. No disease activity was seen in the immediate postoperative period. No significant risk factors for disease recurrence were noted.
With adequate immunosuppression, cataract surgery in eyes with Mooren ulcer was safe and CDVA improved significantly with no disease reactivation immediately after surgery. No proven role of maintenance immunosuppression was observed. The type of cataract surgery had no influence on ulcer reactivation. Patients with a disease-free interval of 6 months or more before surgery and those who had scleral incisions had favorable outcomes.
Hookworm Infestation
2008, Ophthalmology
Epidemiology and Risk Factors
2022, Corneal Emergencies
Hookworms in emergency department: The "vampire" within
2018, Journal of Acute Medicine

View all citing articles on Scopus

: Manuscript no. 2006-336.

: Reprint requests to Dr Muthaiah Srinivasan, Aravind Eye Hospital and PG Institute of Ophthalmology, Madurai, Tamil Nadu, India.

View full text

Original ArticleHookworm Infestation as a Risk Factor for Mooren’s Ulcer in South India

Objective

Design

Participants

Methods

Main Outcome Measure

Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Clin Immunol

The parts concerned in the operations of the eye

Trans Ophthalmol Soc U K

Mooren’s ulcer: two cases occurring after cataract extraction and treated with hydrophilic lens

Ann Ophthalmol

Aetiology and therapy of Mooren’s ulcer

Klin Monatsbl Augenheilkd

Original Article
Hookworm Infestation as a Risk Factor for Mooren’s Ulcer in South India