Correspondence

Mooren's Corneal Ulcers and Hepatitis C Virus Infection

N Engl J Med 1993; 329:62July 1, 1993

Article

To the Editor:

Mooren's corneal ulcer is a chronic, painful, progressive disorder that characteristically affects the peripheral cornea in a circumferential manner1. The disease may be unilateral or bilateral and may progress to involve the entire cornea, resulting in severe visual loss. Although it is occasionally associated with eye surgery, trauma, or herpes zoster, most cases are idiopathic. Treatment with immunosuppression may be beneficial,2 but many cases are refractory to all forms of therapy.

We have identified the presence of hepatitis C virus (HCV) infection in two consecutive patients with this condition. One patient had previously received blood transfusions, and the other reported intravenous drug use. Antibodies to HCV were detected in serum from both patients by a second-generation assay, and HCV genomic RNA by the reverse transcriptase-polymerase chain reaction, with use of nested primers from the highly conserved, 5' untranslated region of HCV. For each patient, a 155-base-pair fragment amplified by the polymerase chain reaction was subjected to complete DNA sequencing to confirm that the fragment was HCV-related. Liver biopsy revealed typical features of chronic active hepatitis in one patient and yielded an entirely normal specimen in the other.

After the failure of immunosuppressive therapy with corticosteroids and cyclophosphamide, treatment with interferon alfa-2b for six months resulted in normalization of aminotransferase levels and marked improvement in the corneal ulcers in the first patient (Figure 1Figure 1Slit-Lamp Photographs of the Left Cornea of a Patient with Mooren's Ulcer.); the improvement has persisted for more than six months without therapy, despite the return of elevated levels of aminotransferases and detectable HCV RNA in the serum. Treatment has continued in the second patient; however, HCV RNA was no longer detectable in the serum after two weeks of interferon therapy, and continuing improvement was noted in both eyes at three months. During this period, the condition abruptly worsened when the patient stopped taking interferon alfa, but improved again when treatment was reinstituted.

Recent clinical studies have established strong epidemiologic links between HCV infection and several disorders, including essential mixed cryoglobulinemia,3 porphyria cutanea tarda,4 and membranoproliferative glomerulonephritis5. Our preliminary observations suggest that Mooren's corneal ulcers may be associated with chronic HCV infection. Interferon alfa therapy may be beneficial to such patients. Consideration should be given to evaluating patients with Mooren's ulcers for the presence of HCV infection and to treating them with interferon if they are infected. Additional investigations are needed to confirm these findings and to elucidate the factors leading to corneal ulceration in such a small fraction of patients with HCV infection.

Steven E. Wilson, M.D.
William M. Lee, M.D.
Carol Murakami, M.D.
Jian Weng, Dr.Sc.
George A. Moninger, M.D.
University of Texas Southwestern Medical Center, Dallas, TX 75235

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Citing Articles (14)

Citing Articles

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   Thomas J Liesegang. 2010. Ocular Viral Infections. , 425-448.
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   Q-S Wang, J Yuan, S-Y Zhou, J-Q Chen. (2008) Chronic hepatitis C virus infection is not associated with Mooren's ulcer. Eye 22:5, 697-700
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   Christina Jacobi, Hartmut Wenkel, Arnd Jacobi, Klaus Korn, Claus Cursiefen, Friedrich E. Kruse. (2007) Hepatitis C and Ocular Surface Disease. American Journal of Ophthalmology 144:5, 705-711.e1
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   C. Schweitzer, D. Touboul, C. Ghiringhelli, J. Colin. (2007) Récurrence d’un ulcère de Mooren après une chirurgie de la cataracte. Journal Français d'Ophtalmologie 30:3, 281.e1-281.e5
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   Ayse Aytaman, Gül Bahtiyar, Samy I McFarlane. (2005) Interferon-α therapy and Type 1 diabetes mellitus in patients with hepatitis C: pathophysiologic insights. Therapy 2:3, 439-446
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