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Dr. Rick
Dr. Rick, Board Certified MD
Category: Eye
Satisfied Customers: 7750
Experience:  Ophthalmology since 1994 with Retina sub-specialty interest
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Had LASIK several years ago with good results, but vision slowly

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Had LASIK several years ago with good results, but vision slowly regressed--mainly mixed astigmatism returned. (Wore contacts prior to LASIK for 20 years) A couple years ago, slowly experienced progressing halos and comets, mostly at night and then somewhat during the day, too. Have chronic, mild/moderate dry eyes. Possible Sjogren's (primary). Had scars prior to LASIK, which caused no issue as they were in periphery. But, post LASIK, the now-diagnosed Salzmann's noduels have caused issues with night driving (halos and comets) and day vision. I had Salzmann's nodulectomy on the left eye a couple months ago. I still have residual ghosting, but vision in that eye is much better. Doctor did scraping method of removal. Did not do diamond burr procedure due to prior LASIK. Is that standard? Is there something else that can be done to improve the resutls? I haven't found much information about Salzmann's nodules online. Can you recomend any good reference materials? How rare are they really? Can LASIK worsen them/cause them?
Thank you.
Submitted: 3 years ago.
Category: Eye
Expert:  Dr. Rick replied 3 years ago.

Dr. Rick :

Hi. I'm online and happy to answer your question today.

Dr. Rick :

Are you available to chat?

Dr. Rick :

Let me start with the last part of your question. Lasik does not cause salmann's nor will it make it worse.

Dr. Rick :

After lasik your cornea is thinner then normal. Because of this there is a higher risk of using a diamond burr after removing the salzmann's nodule from you eye. I would agree with holding off on using this instrument in your case -- grinding through the cornea into the anterior chamber with a diamond burr would be a very, very bad thing :)

Dr. Rick :

There are a number of treatments available for Salzmann's nodular degeneration (snd).

As you know, snd is a rare degenerative condition that has no relationship to inflammation or infection and is slowly progressive. There seem to be various sub-types of snd. One type is elevated and almost "stuck on" the cornea. This type is easily removed with manual scraping and leaves a smooth, intact bowman's layer and cornea behind.

Another type is more firmly attached to the eye and tends to leave a rough surface behind once removed. Removal with a laser (PTK) is best for this sub-type

The most difficult snd's have major peripheral vascularization and grow deeply into bowman's membrane. Removal causes damage to Bowman's and leaves large defects in the corneal stroma. These sub-types are difficult to remove and are best treated with multiple laser ablation procedures using masking techniques to preserve normal tissue areas.

Rarely, the depth of the lesion, the extent of scaring or the loss of stromal tissue from laser ablation is so great that a corneal transplant is necessary.


 

Dr. Rick :

Here is some info on Salzmann's from the Handbook of Ocular disease management: http://legacy.revoptom.com/handbook/SECT28a.HTM

Dr. Rick :





Full Size Image







Salzmann’s Nodular Degeneration

[IMAGE][SRC][/SRC][ALT][/ALT][WIDTH]141.02564102564102[/WIDTH][HEIGHT]100[/HEIGHT][STYLE][/STYLE][/IMAGE]Signs and Symptoms
Most cases of Salzmann’s nodular degeneration present asymptomatically. Discomfort does not usually occur until later stages, at which time recurrent corneal erosion (RCE) may ensue. Patients manifesting RCE typically report photophobia, blepharospasm, tearing, and decreased acuity. In between bouts of RCE, non-specific "dry eye" complaints such as burning or grittiness are typical.


Clinically, Salzmann’s degeneration appears as an accumulation of bluish-white superficial nodules in the mid-peripheral cornea. Generally, the eye is not inflamed unless there is associated corneal erosion. In that event, there will be limbal injection, corneal edema, and an anterior chamber reaction.


There are conflicting reports regarding the laterality of Salzmann’s degeneration; an older study reports a unilateral presentation in 80 percent of cases, while a more recent study suggests a bilateral predilection in 80 percent. The condition is seen more frequently in women than in men.


Patients with Salzmann’s degeneration usually describe a previous episode of ocular inflammation, often in childhood. Associated disorders may include phlyctenular disease, vernal keratoconjunctivitis, trachoma, or interstitial keratitis. Patients with a history of epithelial basement membrane dystrophy or corneal surgery may also be at increased risk.


Pathophysiology
At the cellular level, the nodules seen in Salzmann’s degeneration represent clumped masses of collagen fibrils anterior to Bowman’s membrane. Experts speculate that these peripheral accumulations of collagen are produced by fibroblasts within the conjunctiva or limbal vessels. In some cases, transmission electron microscopy has demonstrated reduplication of the epithelial basement membrane. Descemet’s membrane and the corneal endothelium are characteristically unaltered, however.


One theory behind the development of Salzmann’s degeneration suggests that the inciting corneal inflammation creates an irregular surface, allowing for uneven tear film distribution and exposure. A process known as hyalization ensues, which is the same process responsible for the development of conjunctival pinguecula. As the nodules grow in size, there is progressive damage and scarring at the level of Bowman’s membrane. This ultimately results in epithelial erosion and potential impairment of acuity.


Management
Mildly asymptomatic cases of Salzmann’s degeneration may be managed with topical lubricants and/or a bandage contact lens. Prophylactic antibiosis is advisable if epithelial defects are significant. In more severe cases, superficial keratectomy may be utilized to remove the nodules from the anterior cornea. Phototherapeutic keratectomy (PTK) is also an option. If significant scarring is present, or if chronic epithelial breakdown makes the condition unmanageable, lamellar or penetrating keratoplasty may be the only recourse.


Clinical Pearls




  • The critical issue in managing Salzmann’s degeneration is proper diagnosis. Conditions such as band keratopathy, spheroid degeneration (climatic droplet keratopathy), and corneal keloids may all present with a similar clinical appearance. Consult a corneal specialist in those cases where diagnosis is elusive.




  • It may be tempting to use topical corticosteroids in Salzmann’s degeneration, particularly if the patient is symptomatic. However, since this condition is non-inflammatory in nature, steroids will have little effect. Additionally, the use of steroids introduces an unnecessary risk in patients with a compromised epithelium.





 

Dr. Rick :

There are a number of online pages if you just google "salzmann's nodular degeneration. If you need something more technical I could can and post pages out of an ophthalmology textbook I have, but this might be a little too technical....

Dr. Rick :

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Dr. Rick, Board Certified MD
Category: Eye
Satisfied Customers: 7750
Experience: Ophthalmology since 1994 with Retina sub-specialty interest
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Expert:  Dr. Rick replied 3 years ago.
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Expert:  Dr. Rick replied 3 years ago.
'
Customer: replied 3 years ago.

Dr. Rick,

Thank you for the information. I had found most of that during my own online searches. I have seen three corneal specialists and a group of fellows in San Francisco at UCSF and they all agree I have Salzmann's Nodules. I'm curious as to the occurance of Salzmann's Nodules. What are the statistics for it? I have not met anyone who has them? I am 45 years old, but I understand most cases are diagnosed in people in their sixties. I also understand that even after a Salzmann's Nodulectomy, that there's approx. a 1 in 5 chance of them recurring. I have blespharitis, as well, apparently. So I do eyelid scrubs. I also have punctal plugs, but they have not really helped my dry eye condition. i am hoping to be fitted for a new contact lens prescription after a decision is made on whether to operate on the right eye nodules. Are there statistics for how many people who have worn contact lenses end up with Salzmann's nodules? Just curious. It's a strange thing to go from no glasses or contacts to over the course of several months, losing your night vision and having issues with your daytime vision.

Expert:  Dr. Rick replied 3 years ago.
I am not aware of any correlation to salzmann's nodules and contact lens use and, yes, the nodules can recur. All the data I have read about this condition just calls is "rare" without giving any statistics or numbers. It does, however, sound like you are in excellent hands with the cornea specialists at UCSF.....perhaps they have some of the data you are interested in concerning the incidence of this condition and any association with contact lens use.

Don't forget to press the 'accept' button if you are satisfied with the help I've given you. This allows me to get credit for my time. Positive Feedback and/or Bonus are always appreciated.

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