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Superficial keratectomy for Salzmann nodular degeneration following laser in situ keratomileusis

Published:October 18, 2018DOI:https://doi.org/10.1016/j.jcjo.2018.07.002
      Salzmann nodular degeneration is a slow progressive condition characterized by the presence of gray-white nodules anterior to Bowman's membrane on the cornea.
      • Maharana PK
      • Sharma N
      • Das S
      • et al.
      Salzmann's nodular degeneration.
      It usually affects Caucasian females in their 70s, particularly in patients with prolonged ocular surface inflammation, history of phlyctenular keratitis, vernal keratoconjunctivitis, trachoma, trauma, or previous ocular surgeries.
      • Maharana PK
      • Sharma N
      • Das S
      • et al.
      Salzmann's nodular degeneration.
      • Moshirfar M
      • Marx DP
      • Barsam CA
      • et al.
      Salzmann's-like nodular degeneration following laser in situ keratomileusis.
      With the increasing popularity of LASIK and photorefractive keratectomy, a surprising number of early-onset Salzmann nodules beginning in patients’ 40s have appeared in routine clinical practice.
      • Moshirfar M
      • Marx DP
      • Barsam CA
      • et al.
      Salzmann's-like nodular degeneration following laser in situ keratomileusis.
      • VanderBeek BL
      • Silverman RH
      • Starr CE
      Bilateral Salzmann-like nodular corneal degeneration after laser in situ keratomileusis imaged with anterior segment optical coherence tomography and high-frequency ultrasound biomicroscopy.
      • Lim MC
      • Chan WK
      Salzmann nodular degeneration after laser in situ keratomileusis.
      • Shalchi Z
      • O'Brart DP
      • McDonald RJ
      • et al.
      Eighteen-year follow-up of hyperopic photorefractive keratectomy.
      While many responded with ocular lubrication and lid hygiene management, the disease progresses despite treatment in a small fraction of patients.
      • Stem MS
      • Hood CT
      Salzmann nodular degeneration associated with epithelial ingrowth after LASIK treated with superficial keratectomy.
      This case series reports successful surgical management (superficial keratectomy) of 3 cases of early-onset Salzmann nodules involving the LASIK flap edge.

      Case 1

      A 48-year-old female who underwent microkeratome-assisted LASIK in 1994 presented in 2005 with eye pain and dryness, along with worsening “white growth” on both corneas. A slit-lamp examination revealed Salzmann nodules bilaterally. From 2005 to 2014, despite aggressive ocular lubrication, the patient's corneal nodules expanded. Her uncorrected distance visual acuity (UDVA) was 20/40 in the right eye and 20/50 in the left eye. Corrected distance visual acuity (CDVA) was 20/20 with a refraction of -1.25 +2.75 at 105 in the right and -1.25 +2.75 at 80 in the left. A slit-lamp examination revealed Salzmann nodules bilaterally at 2–4 o'clock and 9–11 o'clock along the LASIK flap margins with scarring (Figs. 1A,1B). Corneal topography showed irregular astigmatism with keratometry of 42.5/34.5 at 106 in the right eye and 41.69/33.93 at 83 in the left.
      Fig 1
      Fig. 1A. Extensive Salzmann nodules from 2–4 o'clock and 9–10 o'clock of right eye in Case 1. B. Extensive Salzmann nodules from 2–4 o'clock and 9–11 o'clock of left eye in Case 1. C. Single Salzmann nodule at 10 o'clock of left eye in Case 2. D. Anterior segment OCT showing Salzmann nodule above Bowman's membrane in Case 2. E. Extensive Salzmann nodule from 10–2 o'clock with denser stromal opacification of right eye in Case 3. F. Anterior segment OCT showing Salzmann nodule above Bowman's membrane in Case 3. G. Mucosal epithelium with subjacent fibrocellular material consistent with Salzmann nodular degeneration in Case 3.
      Superficial keratectomy was performed in 2 sessions for each eye, temporally and then nasally, due to the extensive scaring. Patient was postoperatively managed with 1 week of topical antibiotics and steroids. Two months after superficial keratectomy, the patient's UDVA was 20/25 in the right and 20/30 in the left. Manifest refraction was -1.00 sphere, 20/20 CDVA in the right eye and -0.5, +0.75 at 90, 20/25 CDVA in the left. A slit-lamp exam revealed no elevated nodules, mild punctate epitheliopathy with superficial stromal scarring in both eyes. Corneal astigmatism significantly improved with keratometry reading of 42.1/39.41 at 89 in the right and 41.12/38.53 at 94 in the left.
      At 2-year follow-up, she demonstrated stable CDVA of 20/20 in both eyes with the same refraction. Corneal topography and a slit-lamp exam remained unchanged. Anterior segment ocular coherence tomography (AS-OCT) confirmed no recurrence.

      Case 2

      A 46-year-old male who underwent successful microkeratome-assisted LASIK in 1997 followed by enhancements in both eyes, complicated by corneal ectasia of the left eye, presented in 2016 complaining of blurry vision in the left eye. UDVA was 20/50 in the left eye, CDVA was 20/20 with a refraction of -1.5 +1.75 at 180. A slit-lamp exam was remarkable for a single Salzmann nodule at 10 o'clock on the edge of LASIK flap in the left eye (Fig. 1C). AS-OCT revealed isolated corneal scarring above fragmented Bowman's layer (Fig. 1D). Corneal topography read 40.47/36.91 at 027.
      Superficial keratectomy was performed on the left eye with one week of post-operative antibiotic-steroid regimen. One month later, the patient's UDVA was 20/30 and CDVA to 20/20 with manifest refraction of -1.00 +1.00 at180. A slit lamp examination showed a faint stromal flat scar with no punctate epitheliopathy. Corneal topography of the left eye showed improvement of corneal astigmatism and keratometry readings of 40.25/39.3 at 122.

      Case 3

      A 48-year-old female who underwent microkeratome assisted LASIK in 2002 presented in 2008 with constant eye burning and “whitish growth.” A slit-lamp examination showed central LASIK flap position, superior opacity from 10 to 1 o'clock, along with pannus and pinguecula in both eyes. The patient was managed with aggressive ocular lubrication for the next 8 years, but her Salzmann nodules progressed.
      Immediately prior to superficial keratectomy in 2016, the patient's UDVA was 20/70 on the right and CDVA was 20/20 with a refraction of +1.00 +3.50 at 10. A slit-lamp examination revealed Salzmann nodules bilaterally at 10–2 o'clock on the right and 12–3 o'clock on the left along the LASIK flap edges, with denser stromal opacification on the right (Fig. 1E). Corneal topography revealed irregular corneal astigmatism (right greater than left) with keratometry readings of 43.69/38.32 at 011 on the right. AS-OCT showed more severe hyper-reflective changes in LASIK flaps on the right (Fig. 1F).
      Superficial keratectomy was performed on the right eye with one week of post-operative antibiotic plus steroid regimen. Pathology results showed mucosal epithelium and fibrous issue, consistent with Salzmann nodular changes (Fig. 1G). One month after superficial keratectomy, UDVA was 20/30 and CDVA was 20/20 with a manifest refraction of +1.25 +1.0 at 180. A slit lamp examination revealed a well apposed LASIK flap with no elevated nodules. Corneal topography of the right eye improved to 44.07/41.18 at 10.

      Discussion

      To date, there have been 5 cases of Salzmann degeneration after LASIK procedures described in the literature. Four cases were treated conservatively with artificial tears, topical cyclosporine 0.05%, punctal plugs, and loteprednol.
      • Moshirfar M
      • Marx DP
      • Barsam CA
      • et al.
      Salzmann's-like nodular degeneration following laser in situ keratomileusis.
      • VanderBeek BL
      • Silverman RH
      • Starr CE
      Bilateral Salzmann-like nodular corneal degeneration after laser in situ keratomileusis imaged with anterior segment optical coherence tomography and high-frequency ultrasound biomicroscopy.
      • Lim MC
      • Chan WK
      Salzmann nodular degeneration after laser in situ keratomileusis.
      Only 1, reported by Stem et al, was treated with superficial keratectomy, because the nodule showed extensive involvement around the entire flap circumference.
      • Stem MS
      • Hood CT
      Salzmann nodular degeneration associated with epithelial ingrowth after LASIK treated with superficial keratectomy.
      Similarly, the 3 treatment-resistant cases in this report had symptomatic resolution and vision restoration to 20/20 by 1 month after superficial keratectomy. With standard post-operative treatment of antibiotics and topical steroids, no post-procedural complications were reported. The patients in Case 1 and Case 3 had more extensive nodules and higher levels of irregular astigmatism than all previously reported cases, +8 and +5 cylinder diopters respectively, and yet both patients recovered with much reduced astigmatism after superficial keratectomy. At 2-year follow-up, Case 1 demonstrated stable vision with no signs of recurrence, a reassuring sign of lasting efficacy.

      Conclusion

      Based on this case series and previous publications, the development of Salzmann nodules following LASIK procedures may not be as uncommon as previously understood. Although early asymptomatic cases with mild involvement may be managed medically, this report shows that cases with more extensive flap involvement or severe irregular corneal astigmatism may be more effectively managed with superficial keratectomy.

      Disclosure

      K.E. Donaldson is a consultant for Alcon, Allergan, Abbott Medical Optics, Omeros, TearLab, SUN, Shire.

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