Address Salzmann’s Nodules
October 25, 2010DrHovanesian No Comments »Address Salzmann’s nodules and basement membrane dystrophy before preop cataract measurements
In an era where patients are increasingly conscious of their postoperative refractive results after cataract surgery, whether or not they’re choosing a premium lens implant, it’s important to identify and eliminate potential sources of error in our preoperative measurements. Much has been written about dry eye, but fairly little attention has been drawn to common corneal disorders that can easily be eradicated, or at least reduced in their impact on the results of cataract surgery. Salzmann’s nodular degeneration is a disorder of where fibrotic plaques develop on the surface of Bowman’s membrane, most typically in the peripheral cornea. They frequently occur in the presence of dry eye, blepharitis, and they may be multiple. Even though these are usually a peripheral corneal disorder, they frequently affect the central corneal curvature because the tear film is irregular in and around them. Removing these nodules is fairly straightforward and requires only simple instrumentation.
First, it is worthwhile to come to surgery prepared with a diagram where all the nodules are, because these nodules can be more difficult to identify under an operating microscope than under a slit lamp. In surgery, which can be performed in the office with a decent microscope (some surgeons even do these procedures at the slit lamp), I use a 15 blade scalpel perpendicular to the corneal surface to scrape away first epithelium around the edge of the lesions, and then attempt to lift the edge of the lesion to identify the natural tissue plane between the nodule and the underlying corneal surface. Sometimes continued scraping can allow the entire nodule to be removed, and sometimes fine-toothed (0.12 Castro-Viejo) forceps can be used to pull the nodule off in its entirety.
Once this is done, there is a uniform, somewhat glistening appearance to the intact Bowman’s membrane which has been exposed underneath. This appearance should be consistent across the entire de-epithelialized area of the cornea. At this point, you know you’re done with the procedure.
I place a bandage contact lens on the eye until the epithelium heals and prescribe antibiotics, a topical non-steroidal (for discomfort), and prednisolone acetate, all four-times daily or as indicated by the manufacturer’s packaging.
Epithelial basement membrane dystrophy is a disorder of the epithelium and its basement membrane only. Because the epithelial basement membrane is thrown into folds, this disorder can disrupt the tear film and vision. This is usually evident by negative staining around the raised areas of epithelium when fluorescein is placed in the eye.
Treating epithelial basement membrane dystrophy is as simple as scraping the epithelium from the affected areas, then placing a bandage contact lens and allowing the eye to heal with the same medications described above.
Identifying these two conditions and treating them before preoperative cataract measurements can improve our surgical results and yield even better patient satisfaction.
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