Figure 1. Right anterior eye of 68-year-old Caucasian male Image: Associate Professor Mark Roth
Associate Professor Mark Roth
BSc(Pharmacology) BAppSc(Optom) PGCertOcTher NEWENCO FAAO OAM
A 68-year-old Caucasian male presents, reporting symptoms of a gritty sensation, watery discharge and increasing photophobia in his right eye. Although he says he has been symptomatic for only the past seven months, the patient’s wife reports that the eye has been red for 10 years.
There is conjunctival injection; however, it is not global but restricted to the nasal aspect. The key feature is a raised, yellow-white corneal lesion in the periphery at four o’clock. (Figure 1, arrow)
The shape of the raised lesion is oval and the approximate size is 1.5 mm x 2.0 mm. There is no significant staining of the lesion but there are signs of long-standing dry eye and ocular surface disease.
What is your diagnosis? What is your management?
Figure 2. Post phototherapeutic keratectomy Image: Associate Professor Mark Roth
The patient was diagnosed with Salzmann’s nodule, a degenerative condition of the cornea which appears as creamy white, opaque or semi-opaque, smooth, elevated lesion(s) on the surface of the cornea. Occasionally, they can appear with a yellow or blue tinge.
Salzmann’s nodules are uncommon but the exact incidence is unknown. They are much more prevalent in women than in men.
Salzmann’s nodules are thought to be related to low-grade chronic inflammation; however, some cases appear to be idiopathic.
Nodules are typically composed of collagen plaques with hyaline between the epithelium and Bowman’s layer.
Salzmann’s nodules are known to occur in patients with ocular surface inflammation secondary to meibomian gland dysfunction or dry eye disease, phlyctenular keratitis, vernal keratoconjunctivitis, trachoma, marginal keratitis, corneal trauma and long-term contact lens wear complications.
Commonly associated conditions
Common coexistent conditions include the risk factors as described above in addition to epithelial basement membrane dystrophy and cases that involve corneal surgery complications.
There may be a history of long-standing foreign-body sensation, pain, redness, tearing and photophobia, or minimal to no symptoms. If the nodules are near or on the visual axis, they may affect vision.
Slitlamp examination shows single or multiple elevated yellow or blue/white corneal nodules. Typically, Salzmann’s nodules are peripheral or mid-peripheral, but they may also be paracentral or central. There is no staining with vital dyes. A test to consider is corneal topography to evaluate for corneal astigmatism.
See risk factors (above). Also: corneal keloid and corneal amyloidosis.
If the condition is asymptomatic, no treatment is required other than to decrease risk factors for progression. However, if the condition is symptomatic, treatment may involve lubricants, gels, ointments, pulse-dose topical steroids or topical cyclosporin 0.05% drops.
If the patient is not responding to topical therapy, surgical removal of the nodule may be necessary; phototherapeutic keratectomy is the procedure of choice.
Treat underlying causes.
Maguire J, Murchison A, Jaeger E. Wills Eye Institute. 5-minute ophthalmology consult. 1st ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012. 626-627.