Salzmann's Nodular Degeneration Research Articles

Salzmann Nodular Degeneration in Ocular and Systemic Diseases.

This review aimed to evidence the predisposing conditions for Salzmann nodular degeneration (SND), where particular attention was paid to its association with ocular and systemic diseases. SND is a rare disease characterized by bluish-white nodules located in the mid-periphery of the cornea, which are otherwise completely clear. SND has been found in association with different systemic and ocular diseases, and it may have unilateral or bilateral presentation. Initial forms are only diagnosed occasionally as they are asymptomatic, whereas, in advanced disease, the visual acuity might be seriously impaired. Although SND is well described, its exact etiopathology is currently still unknown and is frequently misdiagnosed. It is associated with ocular surface inflammatory conditions and previous corneal surgery, and it has been described in different systemic diseases. Diagnosis is clinically based with slit lamp examinations, and instrumental assessments with corneal topography permit one to observe the alterations of the corneal profile, whereas anterior segment-optical coherence tomography (AS-OCT) is used to investigate the stromal depth of the nodules. Therapy might be conservative with the objective of improving the ocular surface homeostasis and surgical outcomes, where the aim is to restore the corneal regularity and visual acuity. Ophthalmologists should pay particular attention when detecting nodules in patients with ocular and non-ocular inflammatory diseases to guarantee the patient a timely diagnosis and a better therapeutic outcome. Additionally, collaboration between specialists who deal with treating patients suffering from disorders potentially associated with SND is recommended.

Scleral lenses for visual rehabilitation and improvement of subjective symptoms in Salzmann Nodular Degeneration

Scleral lenses for visual rehabilitation and improvement of subjective symptoms in Salzmann Nodular Degeneration

Salzmann's Nodular Degeneration in Refractive Surgery: The Earlier Hit Hypothesis of EBM Injury-Related Fibrosis of the Subepithelial Space and Deeper Corneal Extension.

To review the atypical development of Salzmann's nodular degeneration (SND) after two cases of laser in situ keratomileusis (LASIK) and one case of photorefractive keratomileusis (PRK), and to highlight the pathophysiology of SND and its treatment. Three cases of SND (two following LASIK performed with microkeratomes and one following PRK) were reviewed and Pubmed.gov and internet searches were performed. SND is myofibroblast-generated fibrosis in the subepithelial space between the epithelium and Bowman's layer that develops years or decades after traumatic, surgical, infectious, or inflammatory injuries to the cornea in which the epithelial basement membrane is damaged in one or more locations and does not fully regenerate. It is hypothesized based on these cases, and the previous immunohistochemistry of other investigators, that myofibroblast precursors, such as fibrocytes or corneal fibroblasts, that enter the subepithelial space are driven to develop into myofibroblasts, which slowly proliferate and extend the fibrosis, by transforming growth factor-beta from epithelium and tears that passes through the defective epithelial basement membrane. These myofibroblasts and the disordered collagens, and other extracellular matrix components they produce, make up the subepithelial opacity characteristic of SND. Nodules are larger accumulations of myofibroblasts and disordered extracellular matrix. If the injury is associated with damage to the underlying Bowman's layer and stroma, as in LASIK flap generation, then the myofibroblasts and fibrosis can extend into Bowman's layer and the underlying anterior stroma. SND fibrosis often extends into Bowman's layer and the anterior stroma if there are associated Bowman's defects, such as incisions or lacerations. In the latter cases, SND frequently cannot be removed by simple scrape and peel, as typically performed for most common SND cases, but can be trimmed to remove the offending tissue. This condition is more accurately termed Salzmann's subepithelial fibrosis. [J Refract Surg. 2024;40(5):e279-e290.].

Combined superficial keratectomy, alcohol delamination and amniotic membrane patch with fibrin glue in Salzmann nodular degeneration.

To describe the outcomes of five Salzmann's Nodular Degeneration (SND) cases treated with a combination of alcohol delamination, superficial keratectomy and amniotic membrane patch with fibrin glue. Five patients affected by SND with significant discomfort and decreased visual acuity were evaluated with refraction, best corrected visual acuity, Break-up time test, corneal topography, Anterior Segment of Optical Coherence Tomography and images of anterior segment with a full slit lamp examination. All the patients underwent alcohol delamination of the corneal epithelium followed by superficial keratectomy to remove the subepithelial nodules. A patch of amniotic membrane was applied to all of them with a ring shape and a banana shape in two patients due to the location of the disease. A bandage contact lens was inserted. The patch was kept in place for 14 days. Another bandage contact lens was inserted for 21 days until the corneal epithelium had completely healed. The surgical procedure was successful in removing the nodules in all patients. Vision was restored in all cases with a significant regularization of the corneal surface and reduction of ocular discomfort. After a 12-month follow-up, none of the patients showed recurrence of the disease. Combining alcohol delamination with superficial keratectomy and amniotic membrane patch with fibrin glue is an effective procedure for the management of SND to regularize the corneal surface and avoid the recurrence of subsequent nodules. This report is the first description of the outcomes of SND cases treated with a combination of the aforementioned techniques.

Manual Superficial Keratectomy Is the First Choice Treatment for Salzmann Nodular Degeneration.

This study aimed to describe the optical and topographic changes after manual superficial keratectomy (MSK) for Salzmann nodular degeneration. This was a descriptive, retrospective study. All patients with a clinical diagnosis of Salzmann nodular degeneration were examined at the Cornea Service of the Instituto Clínico Quirúrgico de Oftalmología (ICQO), Bilbao, Spain, and treated with MSK after presenting ocular discomfort and/or decreased visual acuity. The clinical characteristics (including anterior segment optical coherence tomography and Pentacam topography), treatment regimens, surgical procedures, and outcomes were recorded. Descriptive statistics were constructed using mean ± SD, minimum, maximum, and median. The Shapiro-Wilk normality test was used. The Student t test was used to determine significance. Ten eyes of 9 patients were included in this study: 6 patients (66.6%) were female and 3 were male (33.3%). The mean age was 62.2 years, and the follow-up time was between 5 and 21 months. The best-corrected visual acuity before MSK was 0.20 LogMAR (median) and improved to 0.10 after the surgical procedure. The mean spherical equivalent was reduced from -0.23 ± 3.39 D preoperatively to -1.3 ± 3.0 D postoperatively. Astigmatism decreased between 0.5 and 3.75 D. Topographic irregularity normalized total root mean square from 11,596.4 ± 6854.01 to 4817.2 ± 2725.68 μm. MSK is an effective and safe technique for the treatment of Salzmann nodular degeneration when the Bowman layer is preserved. Anterior segment optical coherence tomography and corneal topography are essential tools for the surgical plan and for the detection of corneal aberrations.

MANIFESTASI KLINIS DAN TATALAKSANA OPERATIF DEGENERASI KORNEA NODULAR SALZMANN

Introduction : Salzmann nodular degeneration (SND) is an idiopathic and degenerative noninflammatory condition of the cornea. SND is characterized by a grayish-white or blue-white subepithelial nodule. Mild symptoms may improve with lubrication and topical anti-inflammatory therapy. Visual disturbances may occur and surgery may be required. Purpose: To explain clinical manifestations and operative management of corneal Salzmann nodular degeneration. Case Report: A 63-year-old woman came with the chief complaint of a nodule in her left eye since 4 months ago. Complaints accompanied by blurry vision, watery eyes and glare. Ophthalmological examination revealed a regression of visual, a nodule in the corneal stroma was grayish white. After examination, the patient was diagnosed with Salzmann OS nodular degeneration and ODS immature senile cataract. Debridement keratectomy and amniotic membrane transplantation (AMT) were performed as the management of this patient. Anatomical pathology results clinically support Salzmann's nodular degeneration. Discussion: Slow-progressive, yellowish-white nodules are characteristic of SND. SND can be asymptomatic, mild symptoms, or until there is a decrease in visual function. It depends on the location and depth of the nodule. Several treatment options can be done ranging from conservative with topical drugs to surgery. Surgical treatment options have the goal of reducing the worsening symptoms of nodule recurrence. Conclusions: A complete history, comprehensive ophthalmological examination can help establish the diagnosis of SND. The appearance of nodules causes complaints of foreign body sensation, decreased visual function and other accompanying symptoms. Treatment needs to be given according to the patient's condition and indications, especially the selection of surgical therapy.

Phototherapeutic Keratectomy for Salzmann's Nodular Degeneration. What Effect Does the Choice of Excimer Laser Have on Treatment Success?

The aim of this study was to assess the difference in treatment success after phototherapeutic keratectomy (PTK) for Salzmann's nodular degeneration (SND) using two excimer lasers with different specifications. 272 PTK procedures, which had been performed on 246 eyes with SND from 181 patients, were retrospectively examined in the period from 2007 to 2017. Until 2014 the excimer laser MEL70 (Carl Zeiss Meditec Vertriebsgesellschaft mbH, Oberkochen, Germany) was used for PTK following manual pannectomy, and after 2014 the excimer laser Amaris 750S (Schwind eye-tech-solutions GmbH, Kleinostheim, Germany) was used. Treatment success was assessed on basis of visual acuity, refraction, and astigmatism, as well as pachymetry and endothelial cell count, recorded at the following time points: T1 = preoperative, T2 = 6-week follow-up, T3 = 6-month follow-up. The Wilcoxon-Mann-Whitney U test and the chi-square test with a significance level of 5% were used to compare the data. A significantly higher improvement of 0.17 ± 0.33 logMAR could be shown for visual acuity in the Schwind group (p < 0.013) after 6 months. In the Zeiss group, visual acuity improved by only 0.11 ± 0.36 (logMAR p < 0.057). Regarding refraction, a significant reduction of the spherical equivalent (SEQ) (p < 0.001) by 3.35 ± 2.76 diopters (D) after 6 months could only be shown for the Schwind group. SEQ did not change significantly in the Zeiss group (p < 0.676). The topographic astigmatism was significantly improved after 6months in both study groups, by 1.73 ± 1.99 D in the Schwind group (p < 0.001) and by 1.99 ± 2.21 D in the Zeiss group (p < 0.0001). Haze had to be treated in 12.7% of the cases in the Schwind group and in 16.2% of the cases in the Zeiss group. No endothelial cell damage was found in either group. In both study groups, the patients with SND clearly benefited from PTK. However, a significantly higher advantage for visual acuity and refraction was shown for the Schwind group compared with the Zeiss group. In contrast to the usual hyperopic effect of PTK in other diagnoses, PTK in SND showed a "myopic shift", which can be explained by the often midperipheral SND nodes and the associated asymmetric tear film pooling prior to surgery.

Salzmann nodular degeneration in posterior keratoconus: a case report

BackgroundTo report an unusual case of salzmann nodular degeneration (SND) in posterior keratoconus (PKC) after a corneal penetrating injury.Case presentationA 56-year-old woman presented with a history of recurrent light sensitivity, foreign body sensation, and tears after a corneal penetrating injury 20 years ago. The patient was diagnosed with SND accompanying with PKC by slit-lamp microscope, anterior segment optical coherence tomography (OCT), and corneal tomography. A combined therapy of medication (0.1% sodium hyaluronate eye drops, recombinant bovine basic fibroblast growth factor eye drops, and 0.1% fluorometholone eye drops) and bandage contact lens could not relieve the latest episode. A phototherapeutic keratectomy (PTK) treatment (laser ablation depth: 15 μm; treatment zone: 7.5 mm) was performed to remove nodules and smooth the surface. The best spectacle-corrected visual acuity improved from 20/63 preoperatively to 20/40 postoperatively. No SND relapse and corneal ectasia were recorded at follow-up 12 months later.ConclusionsThis is the first known, reported case of SND accompanying with PKC after corneal trauma. The PTK is a safe and effective option for SND with PKC.

Peripheral hypertrophic subepithelial corneal degeneration versus Salzmann's nodular degeneration: A clinical and surgical comparison

Peripheral hypertrophic subepithelial corneal degeneration versus Salzmann's nodular degeneration: A clinical and surgical comparison

Optimizing the ocular surface prior to cataract surgery.

Ocular surface disease can significantly impact the outcomes of cataract surgery. Recent studies have examined the efficacy of several new dry eye disease (DED) therapies, the extent to which epithelial debridement affects keratometric measurements in epithelial basement membrane dystrophy (EBMD) and Salzmann nodular degeneration (SND), and the predictability of refractive error following combined pterygium and cataract removal. This review aims to incorporate these newer studies in updating and further emphasizing the need for careful management and optimization of common ocular surface conditions prior to cataract surgery. Common ocular surface conditions such as DED, EBMD, SND, and pterygium can cause significant irregular astigmatism and higher-order aberrations. Their resolution can substantially alter biometry measurements in preparation for cataract surgery, affecting the final visual outcome. Newer therapies for DED, such as topical lifitegrast and thermal pulsation treatment, can aid in this optimization process. If superficial keratectomy or excisions of lesions on the ocular surface are performed, sufficient healing time is needed to allow the ocular surface to reach stability prior to biometry measurements. Ocular surface optimization is key to successful cataract surgery planning and reaching desired outcomes.

Peripheral Hypertrophic Subepithelial Corneal Degeneration.

The purpose of this study was to report a large series of patients with peripheral hypertrophic subepithelial corneal degeneration (PHSCD) and differentiate the condition from Salzmann nodular degeneration (SND). We retrospectively reviewed the charts of 49 patients diagnosed with PHSCD and reported their clinical, refractive, and topographic/tomographic findings. Most of the eyes were white and quiet. Minimal variable injection was present in a few eyes usually in the presence of pseudopterygium. Typical corneal involvement consists of peripheral circumferential-elevated whitish subepithelial opacities with fine superficial vessels along the limbus and linear deposits of iron in the epithelium along the central edge of the opacification. The typical topographic/tomographic findings consist of flattening directly over the corneal opacification with central flattening aligning with the axis of the opacification. In all subjects, the mean refractive astigmatism was significantly less than the mean topographic/tomographic Sim K astigmatism. Thirty-five eyes underwent surgical excision. The surgical eyes demonstrated significantly less astigmatism and better best-spectacle corrected visual acuity than pre-op. Moreover, all the eyes that underwent surgery for discomfort experienced significant improvement in their symptoms. Histopathology of the keratectomy specimens demonstrated paucicellular subepithelial fibrosis with overlying epithelium that was variable in caliber. PHSCD is distinct from SND, primarily occurring in middle-aged women, bilateral and fairly symmetric with larger more peripheral opacities than SND, and absence of inflammatory signs and symptoms.

Salzmann's nodular degeneration

Salzmann nodular corneal degeneration is a non-inflammatory, progressive corneal degeneration characterized by bluish-white nodules of varying shapes classically located in the mid-peripheral cornea. It was first described by Maximilian Salzmann in 1925 and was noted at that time to be associated with “eczematous keratoconjunctivitis”. Since then, significant progress has been made to understand environmental and genetic risk factors associated with SND. However, etiopathogenesis remains poorly understood. A review of the literature was performed to highlight our recent understanding of SND and its management.

Superficial keratectomy followed by intense pulsed light for Salzmann’s nodular degeneration and coexisting meibomian gland dysfunction

To describe the clinical course of a case of bilateral Salzmann nodular degeneration (SND) treated with superficial keratectomy (SK) followed by intense pulsed light (IPL) for the treatment of coexisting meibomian gland dysfunction (MGD). A 54-year-old man who presented to us complaining of progressive blurred vision associated with foreign body sensation in both eyes because of SND and coexisting MGD. In view of symptoms and visual acuity (VA) deterioration, bilateral SK was performed. Two months after SK, IPL treatment to the face and meibomian gland expression (MGX) using the E-eye device (E-SWIN, Paris) on days 0, 15, and 45, were performed in both eyes with the aim to avoid recurrence and/or progression of MGD. One year after SK, the patient was asymptomatic and VA was 20/20 in both eyes; however because of worsening of non-invasive tear film break-up time measured on Sirius® Scheimpflug tomograph, IPL and MGX were promptly repeated and scheduled every 6 months. In our case, IPL was a safe and effective option to control MGD in a patient with SND requiring SK with no observed recurrence of SND 2 years after surgery.

Matching the Patient to the Intraocular Lens: Preoperative Considerations to Optimize Surgical Outcomes

The intraocular lens (IOL) selection process for patients requires a complex and objective assessment of patient-specific ocular characteristics, including the quality and quantity of corneal astigmatism, health of the ocular surface, and other ocular comorbidities. Potential issues that could be considered complications after surgery, including dry eye disease, anterior or epithelial basement membrane dystrophy, Salzmann nodular degeneration, and pterygium, should be addressed proactively. Aspheric IOLs are designed to eliminate the positive spherical aberration added by traditional IOLs to the pseudophakic visual axis. Spherical aberration may be a consideration with patient selection. Patient desire for increased spectacle independence after surgery is one of the main drivers for the development of multifocal IOLs and extended depth-of-focus (EDOF) IOLs. However, no one single multifocal or EDOF IOL suits all patients' needs. The wide variety of multifocal and EDOF IOLs, their optics, and their respective impact on patient quality of vision have to be understood fully to choose the appropriate IOL for each individual, and surgery has to be customized. Patients who have undergone previous LASIK or who have radial keratotomy and ocular pathologic features, including glaucoma, age-related macular degeneration, and epiretinal membrane, require specific considerations for IOL selection. Subjectively, patient-centered considerations, including visual goals, lifestyle, personality, profession, and hobbies, are key elements for the surgeon to assess and factor into an IOL recommendation. This holistic approach will help surgeons to achieve optimal surgical outcomes and to meet (and exceed) the high expectations of patients.

Corneal degenerations in central India: Clinical profile and visual impact

Corneal degenerations in central India: Clinical profile and visual impact - IJCEO- Print ISSN No: - 2395-1443 Online ISSN No:- 2395-1451 Article DOI No:- 10.18231/j.ijceo.2019.115, Indian Journal of Clinical and Experimental Ophthalmology-Indian J Clin Exp Ophthalmol

&lt;p&gt;Salzmann nodular degeneration: prevalence, impact, and management strategies&lt;/p&gt;

PurposeThis review will summarize the clinical and histological presentation of Salzmann nodular degeneration (SND), its prevalence and risk factors, potential underlying mechanisms, diagnostic tools, management options, and impact on cataract surgery and co-morbid ocular surface diseases.MethodPubMed review of 44 articles published between 1976 and 2018.ResultsSND is a corneal disease characterized by whitish gray or bluish nodules on the peripheral or central cornea. The clinical presentation of SND is variable and the nodules can be asymptomatic or cause foreign body sensation and/or blurred vision. Histologically, SND appears as subepithelial nodules with thin overlying epithelium, disrupted or absent Bowman’s layer, and activated fibroblasts within the nodule. SND pathogenesis is not fully understood but is thought to involve poor epithelial protection and disruption of the epithelial–stromal interface, allowing for penetration of epithelially derived growth factors into the stroma and subsequent activation of stromal fibroblasts, eventually leading to sub-epithelial deposition of disorganized extracellular membrane components. SND most commonly occurs in Caucasian females in a bimodal distribution, occurring in the fifth or eighth and ninth decades of life. Risk factors for SND include ocular surface diseases and surgery. Surgical intervention is recommended in individuals with symptomatic nodules – primarily superficial keratectomy performed with or without intraoperative mitomycin C, photokeratectomy, and/or amniotic membrane transplantation. These procedures have been successful in removing the lesion and reducing corneal irregularity, but have variable recurrence rates (0–31%).ConclusionThe pathogenesis of SND is complex and multifactorial. Advances in diagnostic and treatment modalities have allowed for earlier and more accurate diagnosis and effective treatment of SND.

Impact of epithelial basement membrane dystrophy and Salzmann nodular degeneration on biometry measurements

To determine the effects of epithelial basement membrane dystrophy (EBMD) and Salzmann nodular degeneration (SND) on optical biometry measurements. Department of Ophthalmology, Duke University Eye Center, Durham, North Carolina, USA. Retrospective case series. Cataractous eyes with EBMD or SND scheduled for superficial keratectomy (SK) or phototherapeutic keratectomy (PTK) had baseline biometry. Repeat biometry was performed 30days or more postoperatively and compared with baseline. The primary outcome measures were keratometry (K) values, axial length and magnitude, and axis of corneal astigmatism. Secondary outcome measures were the change in intraocular lens (IOL) power, toricity, and axis. In the EBMD group (26 eyes), the mean absolute intersession difference showed an increase in mean K values (P<.001) and a change in IOL spherical power predicting a postoperative spherical equivalent (SE) closest to zero (P<.001) in 21 of 26 eyes (8=0.5 diopter [D]; 9=1.0 D; 4>1.0 D). In toric IOL-eligible eyes, the recommended IOL toricity changed for 16 of 24 eyes, with a mean cylinder power change of 1.2 D. In the SND group (13 eyes), the mean absolute intersession difference showed an increase in mean K values (P=.023) and a change in IOL spherical power predicting a postoperative SE closest to zero (P<.001) in 11 of 13 eyes (3=0.5 D; 3=1.0 D; 5>1.0 D). The recommended IOL toricity changed for 10 of 11 eyes (mean cylinder power change 1.5 D). Both EBMD and SND altered K measurements as evidenced by clinically significant changes in keratometry after SK or PTK. These changes affected the spherical and toric IOL power. Appropriate management of EBMD and SND before cataract surgery can yield more reliable biometric data for surgical planning.

Management of Salzmann's nodular degeneration by scleral contact lenses

Management of Salzmann's nodular degeneration by scleral contact lenses

Superficial keratectomy: indications and outcomes

IntroductionTo evaluate the indications and outcomes of manual blade superficial keratectomy Study designRetrospective, nonrandomized, consecutive case series MethodsDatabase search of patients from 2012-2017 who underwent superficial keratectomy was conducted at a tertiary care hospital cornea clinic. Charts of 121 patients (156 eyes) were reviewed who had at least 4 weeks of follow-up and both preoperative and postoperative measurements of best-corrected visual acuity or corneal cylinder. Outcome measures included: patient demographics, surgical indication, prior ocular history, best-corrected visual acuity (BCVA) changes, corneal and refractive astigmatism changes, recurrence of pathology, additional treatments required, and intraoperative and postoperative complications. ResultsMean patient age at time of operation was 63.3 (±14.8), 39% were male. Indications included epithelial basement membrane dystrophy, recurrent corneal erosion syndrome, Salzmann nodular degeneration, band keratopathy, and suspected ocular surface neoplasia. In eyes with epithelial basement membrane dystrophy, mean BCVA (20/47 to 20/40, P = 0.033), refractive astigmatism (1.76 ± 1.83 D to 1.15 ± 1.08 D, P = 0.010), and corneal astigmatism (1.44 ± 0.88 D to 1.06 ± 0.88 D, P = 0.022) significantly improved. Twenty-four percent (5/21) of eyes with recurrent erosions had symptoms return at a mean 6.5 months follow-up. No intraoperative complications were noted. The epithelium healed completely in all 156 eyes at final follow-up. ConclusionSuperficial keratectomy is a simple, safe procedure that can be performed for a variety of conditions to improve visual acuity, reduce corneal astigmatism, and alleviate symptoms secondary to ocular surface pathology.

Salzmann nodular degeneration after photorefractive keratectomy for hyperopia

Purpose: To report a case of bilateral central Salzmann nodular degeneration (SND) after photorefractive keratectomy (PRK) for hyperopia.Methods: Case report.Results: A 47-year-old male presented with complaints of glare and difficulty with night driving. He had undergone PRK for hyperopia (+3.5+1.5x180 in the right eye and +4.5+1.0x180 in the left eye) in both eyes about 15 years back. The early postoperative period was uneventful; however, he started having these symptoms after two to three months. At presentation, uncorrected visual acuity was 20/100 and best corrected visual acuity was 20/30 with +3.5+1.0x180 in both eyes. Slit-lamp examination showed bilateral 1-1.5 mm diameter, bluish white nodular lesions involving the central corneas. There were also prominent paracentral brown pigment ring deposits consistent with pseudo-Fleischer rings in both eyes. Scheimpflug images showed dense hyper-reflective nodules that were associated with elevated anterior corneal surface and measured 290 μm in the right eye and 230 μm in the left eye, along with presence of significant astigmatism (K1- 45.1D, K2- 47.8D right eye and K1- 45.4D, K2- 49.2D left eye). Central pachymetry was 485 μm in the right eye and 464 μm in the left eye.Conclusions: SND is a rare complication of PRK for hyperopia that can lead to suboptimal visual outcome. PRK should be included in the list of etiologies leading to SND.