{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T17:57:59Z","timestamp":1790791079025,"version":"4.1.0"},"reference-count":17,"publisher":"Public Library of Science (PLoS)","issue":"9","license":[{"start":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T00:00:00Z","timestamp":1790726400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To evaluate the clinical outcomes of a Severity-Based Surgical Algorithm for treating refractory Mooren\u2019s ulcer.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We retrospectively reviewed consecutive patients with Mooren\u2019s 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 &lt;2\/3 stromal thickness; lamellar keratoplasty (LK) for ulcers \u22652\/3 thickness or perforations \u22644 mm; and penetrating keratoplasty (PK) for perforations &gt;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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The cohort comprised 24 patients (24 eyes) with a mean follow-up of 30 months (range 12\u201384). 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 \u2265\u20090.3) 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).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>A severity-graded surgical approach effectively preserves globe integrity in refractory Mooren\u2019s 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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0359413","type":"journal-article","created":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T17:27:36Z","timestamp":1790789256000},"page":"e0359413","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Evaluation of a severity-based surgical strategy for refractory Mooren\u2019s ulcer: A retrospective series with long-term follow-up"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0009-0009-8531-620X","authenticated-orcid":true,"given":"Minghai","family":"Huang","sequence":"first","affiliation":[{"name":"The Second Affiliated Hospital of Guangxi Medical University","place":["Nanning, China"],"department":["Department of Ophthalmology"]},{"name":"Nanning Aier Eye Hospital","place":["Nanning, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zhifeng","family":"Wu","sequence":"additional","affiliation":[{"name":"Nanning Aier Eye Hospital","place":["Nanning, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dongmei","family":"Wei","sequence":"additional","affiliation":[{"name":"Nanning Aier Eye Hospital","place":["Nanning, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jixiao","family":"Nong","sequence":"additional","affiliation":[{"name":"Nanning Aier Eye Hospital","place":["Nanning, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zhuoyuan","family":"Zhang","sequence":"additional","affiliation":[{"name":"Nanning Aier Eye Hospital","place":["Nanning, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thuthuy","family":"Hoang","sequence":"additional","affiliation":[{"name":"Nanning Aier Eye Hospital","place":["Nanning, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Guina","family":"Yin","sequence":"additional","affiliation":[{"name":"Nanning Aier Eye Hospital","place":["Nanning, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,9,30]]},"reference":[{"issue":"1","key":"pone.0359413.ref001","article-title":"Interventions for Mooren\u2019s ulcer","volume":"2014","author":"MB Alhassan","year":"2014","journal-title":"Cochrane Database Syst Rev"},{"issue":"11","key":"pone.0359413.ref002","doi-asserted-by":"crossref","first-page":"1244","DOI":"10.1136\/bjo.84.11.1244","article-title":"Mooren\u2019s ulcer in China: a study of clinical characteristics and treatment","volume":"84","author":"J Chen","year":"2000","journal-title":"Br J Ophthalmol"},{"issue":"1","key":"pone.0359413.ref003","first-page":"7","article-title":"Mooren\u2019s ulcer: current concepts in management","volume":"45","author":"VS Sangwan","year":"1997","journal-title":"Indian J Ophthalmol"},{"issue":"1","key":"pone.0359413.ref004","first-page":"23","article-title":"Cyanoacrylate adhesive with conjunctival resection and superficial keratectomy in Mooren\u2019s ulcer","volume":"44","author":"V Agrawal","year":"1996","journal-title":"Indian J Ophthalmol"},{"issue":"7","key":"pone.0359413.ref005","doi-asserted-by":"crossref","first-page":"971","DOI":"10.1136\/bjophthalmol-2015-307350","article-title":"Efficacy of conjunctival resection with cyanoacrylate glue application in preventing recurrences of Mooren\u2019s ulcer","volume":"100","author":"I Lal","year":"2016","journal-title":"Br J Ophthalmol"},{"issue":"11","key":"pone.0359413.ref006","doi-asserted-by":"crossref","first-page":"1391","DOI":"10.1136\/bjophthalmol-2012-302627","article-title":"Immunosuppression for Mooren\u2019s ulcer: evaluation of the stepladder approach--topical, oral and intravenous immunosuppressive agents","volume":"97","author":"JN Ashar","year":"2013","journal-title":"Br J Ophthalmol"},{"issue":"11","key":"pone.0359413.ref007","doi-asserted-by":"crossref","first-page":"1364","DOI":"10.1136\/bjophthalmol-2013-303359","article-title":"Immunotherapy for corneal inflammatory disorders: stepping up and down the ladder","volume":"97","author":"VPJ Saw","year":"2013","journal-title":"Br J Ophthalmol"},{"issue":"4","key":"pone.0359413.ref008","doi-asserted-by":"crossref","first-page":"675","DOI":"10.1080\/09273948.2021.2023581","article-title":"Effect of anti-TNF treatment on Mooren\u2019s ulcer: a case series and review of the literature","volume":"31","author":"A Xia","year":"2023","journal-title":"Ocul Immunol Inflamm"},{"issue":"4","key":"pone.0359413.ref009","doi-asserted-by":"crossref","first-page":"694","DOI":"10.1016\/S0161-6420(01)01032-6","article-title":"Amniotic membrane grafts for nontraumatic corneal perforations, descemetoceles, and deep ulcers","volume":"109","author":"A Solomon","year":"2002","journal-title":"Ophthalmology"},{"issue":"5","key":"pone.0359413.ref010","doi-asserted-by":"crossref","first-page":"386","DOI":"10.1111\/j.1442-9071.2010.02479.x","article-title":"Amniotic membrane transplantation for Mooren\u2019s ulcer","volume":"39","author":"ND Ngan","year":"2011","journal-title":"Clin Exp Ophthalmol"},{"issue":"2","key":"pone.0359413.ref011","doi-asserted-by":"crossref","first-page":"637","DOI":"10.1097\/SCS.0000000000007063","article-title":"Comparative study on the efficacy of frozen amniotic membrane transplantation and lamellar keratoplasty in the treatment of Mooren ulcer","volume":"32","author":"Y Chen","year":"2021","journal-title":"J Craniofac Surg"},{"key":"pone.0359413.ref012","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1186\/1471-2415-13-81","article-title":"Amniotic membrane transplantation ineffective as additional therapy in patients with aggressive Mooren\u2019s ulcer","volume":"13","author":"M Schallenberg","year":"2013","journal-title":"BMC Ophthalmol"},{"issue":"6","key":"pone.0359413.ref013","doi-asserted-by":"crossref","first-page":"778","DOI":"10.1136\/bjophthalmol-2014-306012","article-title":"Modified lamellar keratoplasty and immunosuppressive therapy guided by in vivo confocal microscopy for perforated Mooren\u2019s ulcer","volume":"99","author":"J Liu","year":"2015","journal-title":"Br J Ophthalmol"},{"key":"pone.0359413.ref014","doi-asserted-by":"crossref","first-page":"8978527","DOI":"10.1155\/2017\/8978527","article-title":"Clinical characteristics and risk factors of recurrent Mooren\u2019s ulcer","volume":"2017","author":"L Yang","year":"2017","journal-title":"J Ophthalmol"},{"issue":"21","key":"pone.0359413.ref015","article-title":"Risk factors for recurrence of Mooren\u2019s ulcer after keratoplasty","volume":"10","author":"S Ou","year":"2024","journal-title":"Heliyon"},{"issue":"1","key":"pone.0359413.ref016","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1002\/micr.10091","article-title":"Microsurgical treatment of Mooren\u2019s corneal ulcer","volume":"23","author":"H Xie","year":"2003","journal-title":"Microsurgery"},{"issue":"6","key":"pone.0359413.ref017","doi-asserted-by":"crossref","first-page":"816","DOI":"10.1016\/j.survophthal.2016.12.010","article-title":"Management of high-risk corneal transplantation","volume":"62","author":"A Di Zazzo","year":"2017","journal-title":"Surv Ophthalmol"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0359413","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T17:27:39Z","timestamp":1790789259000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0359413"}},"subtitle":[],"editor":[{"given":"Vaitheeswaran Ganesan","family":"Lalgudi","sequence":"first","affiliation":[{"name":"University at Buffalo Jacobs School of Medicine and Biomedical Sciences: University at Buffalo School of Medicine and Biomedical Sciences","place":["UNITED STATES OF AMERICA"]}],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,9,30]]},"references-count":17,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,9,30]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0359413","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,30]]}}}