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    Rituximab appears to cure Mooren’s ulcers in 5 patients

    Mooren’s ulcers completely healed in 5 patients treated with rituximab after conventional treatment failed, according to researchers.

    “Additional studies should assess the role of this biotherapy in the management of immunological corneal ulcer,” wrote Dr Damien Guindolet from Fondation A. de Rothschild in Paris, France, and colleagues in the British Journal of Ophthalmology.

    This case series is the first report the authors could find of rituximab being used for this indication.

    A rare corneal ulcerative keratitis, Mooren’s ulcer begins peripherally from the limbus and progresses circumferentially and centrally.

    Much about its aetiology remains poorly understood. But researchers believe it involves loss of tolerance to corneal stroma autoantigen by both cellular and humoral components of the immune system.

    Discerning two types

    Mooren’s ulcers fall into two types: a unilateral peripheral ulcer occurring in elderly Caucasian patients that typically yields to topical steroids, and a bilateral form appearing in young patients—often of African heritage—that requires significant systemic immunosuppression to treat.

    The severe inflammation can result in conjunctivalisation or corneal melting and perforation. Corticosteroids are the mainstay of treatment. Conjunctival resection can prevent immune cell infiltration and keratoplasty may be used in cases of severe corneal thinning or perforation, but such surgery is performed with local or systemic immunosuppression.

    Cyclophosphamide has been recommended for refractory cases, but the recommendation is based on small case series, and this medication can cause haemorrhagic cystitis, neoplasia, and infertility.

    Based on the involvement of humoral immunity in the pathogenesis of Mooren’s ulcer, Guindolet et al. hit upon the idea of treating it with rituximab. A chimeric human and murine anti-CD20 monoclonal antibody, rituximab has treated various autoimmune diseases refractory to conventional treatment, including ulcerative keratitis associated with granulomatosis with polyangiitis.

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