Corneal irregularities can be treated and resolved without complicated surgery in some cases.
Salzmann's nodular degeneration
This pathology appears a creamy white mild to moderately elevated lesion often in the peripheral cornea, but occasionally is seen centrally. It can be associated with EBMD and can cause dry eye symptoms and irregular astigmatism despite a peripheral location.
Dr. Rapuano advised treating in the presence of any centrally located irregular astigmatism. If the patient is awaiting a cataract or refractive surgery, he also suggested waiting about six weeks after treatment before rechecking the biometry before any surgery.
The treatment options include lamellar keratectomy using a blade with or without diamond burr polishing. In some cases, he noted, the nodules will easily peel off of Bowman’s layer and leave a smooth surface. In cases in which the underlying stroma remains unsmooth, he performs excimer laser PTK with or without mitomycin C (MMC).
If PTK is performed, he usually uses MMC. During this procedure, he advises using a blade to remove the nodules and subepithelial fibrosis and then smooth the surface with PTK. MMC 0.02% should be applied on an 8-mm sponge for 60 seconds and then irrigated with 30 cc of saline.
This pathology, which appears as a white calcium deposit, is often related to chronic inflammation but may be idiopathic. If located centrally, the vision can be affected. However, if elevated and in the periphery vision also can be affected. In cases when it is elevated or irregular, it can cause patient discomfort.
Dr. Rapuano advised performing a workup to determine the etiology.
The treatment is ethylenediaminetetraacetic acid (EDTA) chelation. The key point in this procedure is removal of the epithelium over all of the calcium using a number 15 blade or Tooke knife. The presence of any epithelium will prevent absorption of the EDTA. Diluted EDTA 3% to 4% should be applied to the calcium on a cellulose sponge or cotton-tipped applicator for 10 to 45 minutes until all of the calcium has dissolved.
“Corneal irregularities and opacities are common and they can affect comfort, clarity, and corneal curvature, making it especially important to diagnose before cataract and refractive surgeries,” Dr. Rapuano concluded. “There are numerous techniques to identify them, and there are excellent treatment options for clinically relevant pathology.”
Christopher Rapuano, MD
E: [email protected]
This article is based on Dr. Rapuano’s presentation at the American Academy of Ophthalmology 2019 annual meeting. Dr. Rapuano has no financial interest in any aspect of this report.