Salzmann's Nodules: Treatment with Superficial Keratectomy

If you’ve been told you have Salzmann’s nodules (or Salzmann’s nodular degeneration, to give it its formal name), here is the first thing to know: they are completely benign. These little bumps on the cornea are not a growth to fear, and when they do start causing trouble, removing them is about as gentle as eye surgery gets.

What are Salzmann’s nodules?

Salzmann’s nodules are smooth, raised, bluish-grey or white mounds of scar-like tissue that form on the surface of the cornea, the clear window at the front of the eye. They usually develop slowly over years, often sitting quietly out towards the edge of the cornea where you’d never know they were there.

Many are found by chance during a routine eye exam. But as they grow or creep towards the centre, they can cause a gritty, foreign-body feeling, irritation in the wind or air-conditioning, and blurred vision — because a bump on the cornea warps its shape and creates irregular astigmatism that glasses can’t fully correct.

What causes Salzmann’s nodular degeneration, and why mostly women?

The honest answer is that we don’t completely understand the cause. What we do know is that most nodules grow on corneas that have been irritated for a long time: chronic dry eye or blepharitis (inflammation of the eyelid margins), years of contact lens wear, previous eye surgery or old episodes of inflammation can all set the stage. In some patients they appear with no obvious trigger at all.

Salzmann’s nodules are also far more common in women, typically in middle age or later. Hormonal influences on the ocular surface are suspected to play a part, but the full story is still being worked out. If that’s you, nothing you did brought them on.

Superficial keratectomy: the main treatment

When nodules are small and quiet, they can simply be watched, with lubricating drops to keep the surface comfortable. But once they cause persistent irritation or affect your vision, the treatment of choice is superficial keratectomy. It is far less dramatic than it sounds.

Salzmann’s nodules sit on the cornea rather than in it, separated from the deeper tissue by a natural plane of separation. That means they can usually be peeled away cleanly, a little like lifting a sticker off glass, leaving the healthy cornea beneath untouched. There is no cutting into the eye and no stitches, and with anaesthetic drops the procedure itself is painless — most patients are surprised it’s already over.

You can watch me remove Salzmann’s nodules in this short video:

Afterwards, a soft bandage contact lens protects the eye while the surface skin layer heals. Most eyes feel a little gritty for the first day or two, then settle quickly as the surface heals under the bandage lens. The cornea regains its smooth shape, and vision typically improves as the irregular astigmatism settles.

One situation where removal really matters: before cataract surgery. Nodules distort the corneal measurements used to calculate your lens implant, so I remove them first, let the surface settle, and re-measure, so your cataract surgery can be planned with accurate numbers rather than estimates.

Where does PTK fit in?

For some patients I add a phototherapeutic keratectomy (PTK) — an excimer laser polish of the corneal surface — after the nodules are peeled. PTK is useful when the surface underneath is left slightly uneven, when nodules have recurred before, or when fine scarring needs smoothing to get the best optical result. It’s the same laser family we use for vision correction, used here purely to restore a perfectly smooth surface. You can read more in my article on topography-guided PTK for corneal scarring.

Gritty eyes or blurring vision? Get them looked at

Salzmann’s nodules are benign, slow and very treatable. If yours have started to irritate or blur, a quick corneal assessment will show whether a simple superficial keratectomy could make your eyes comfortable and clear again.