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42 EW FEATURE Mooren's continued from page 41 February 2011 Corneal diagnoses and systemic disease April 2012 An example of Mooren's ulcer PUK with scleritis in a patient with RA Source (all): Virender S. Sangwan, M.D. PUK is caused by a limited num- ber of things, Dr. Foster said. For ex- ample, if a patient has peripheral keratitis and there are white blood cells infiltrated into the stroma, that may just be a hypersensitivity reac- tion to staphylococcal protein, not PUK. "If you cling to the definition that I laid out for PUK, now you've got a person who might have Mooren's ulcer or alternatively might have the peripheral corneal disease as a consequence of a poten- tially lethal systemic vasculitis; those diseases include granulomatosis with polyangiitis (Wegener's), polyarteri- tis nodosa, and then a couple of the other classic rheumatologic disor- ders," he said. Distinguishing between Mooren's disease and PUK The characteristics of PUK and Mooren's ulcer are very much the same as the characteristics in a per- son with polyarteritis or granulo- matosis with polyangiitis, or relapsing polychondritis or rheuma- toid disease, Dr. Foster said. The characteristics include an ulcer progressing slowly and easily, circumferentially, and deeper toward the center of the cornea. If one uses a fine instrument to explore the ulcer, one will find that it has an overhanging lip; if this fine instru- ment is exploring the ulcer toward the center of the cornea, one can be absolutely astonished at how far into the cornea the instrument can go before it meets resistance. In other words, there's a lot more de- struction than is clinically apparent at the slit lamp, Dr. Foster said. Therefore, a very thorough sys- temic evaluation is mandatory in any patient that is believed to have Mooren's ulcer, Dr. Foster said. In fact, the diagnosis should be PUK from the beginning; then, if the aggressive systemic evaluation is negative and the adjacent sclera is not involved, it's appropriate to hang the label Mooren's ulcer on this patient, he said. Dr. Foster added, "The systemic evaluation should not discover that the patient has an elevated C-reac- tive protein, an elevated sedimenta- tion rate, auto-antibody production