Bilateral Salzmann-like nodular corneal degeneration after laser in situ keratomileusis imaged with anterior segment optical coherence tomography and high-frequency ultrasound biomicroscopy Brian L. VanderBeek, MD, MPH, Ronald H. Silverman, PhD, Christopher E. Starr, MD Examination of a 34-year-old patient 7 years after laser in situ keratomileusis (LASIK) showed Salzmann-like nodules in both eyes, causing irregular astigmatism and decreased visual acuity. Two new imaging modalities were used to demonstrate the characteristics of this complication. Anterior segment optical coherence tomography (OCT) (Visante) scans showed hyperreflective nodules that varied in thickness from 0.35 mm to 0.56 mm. High-frequency ultrasound biomicro- scopy illustrated the destruction of Bowman layer underlying these lesions. Both modalities dem- onstrated nodules as hyperreflective material covered by an abnormally thin layer of epithelium. Salzmann-like nodular degeneration is a rare but possible cause of decreased visual acuity and irregular astigmatism after LASIK surgery. Ultrasound biomicroscopy and OCT can demonstrate many of the established histopathologic findings in vivo. J Cataract Refract Surg 2009; 35:785–787 Q 2009 ASCRS and ESCRS Salzmann, an Austrian ophthalmologist, first de- scribed the clinical entity of corneal nodular degenera- tion after observing 23 cases that occurred several years after corneal insults. 1 Since then, Salzmann nodular de- generation has been further characterized as nonin- flammatory, blue-gray, subepithelial nodules often found in, but not limited to, the midperipheral cornea. 2 Patients can be asymptomatic or have complaints sec- ondary to dry-eye irritation and recurrent erosions. 3 Salzmann nodular degeneration has been associated with a variety of corneal diseases including vernal keratoconjunctivitis, phlyctenular keratitis, and tra- choma, as well as noninflammatory conditions such as clear corneal cataract incisions and contact lens use. 1–3 To our knowledge, only one study has associ- ated laser in situ keratomileusis (LASIK) surgery and Salzmann nodular degeneration. 4 We report a case that further illustrates this rare complication of LASIK surgery and demonstrates the characteristics on ante- rior segment optical coherence tomography (OCT) and high-frequency ultrasound biomicroscopy (UBM). CASE REPORT A healthy 34-year-old woman presented for initial evalua- tion with complaints of blurry vision, photosensitivity, irrita- tion, and dry eyes. The ocular history was significant for LASIK surgery performed 7 years previously by an outside ophthalmologist. Review of the patient’s medical record showed the preoperative manifest refraction was À0.50 À0.75 Â 150 in the right eye and À0.75 À1.50 Â 35 in the left eye. The initial LASIK surgery was abandoned after an incomplete flap occurred in the right eye. Two weeks later, LASIK surgery was performed in the left eye and 6 months later, in the right eye without complication. Immediately af- ter the surgery, the uncorrected visual acuity (UCVA) was 20/20 in both eyes. Eight months later, the patient returned complaining of blurry vision in the right eye and the appearance of ‘‘some- thing on the cornea where the flap was made.’’ Dry eye Submitted: June 19, 2008. Final revision submitted: September 23, 2008. Accepted: September 25, 2008. From the Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York, USA. Dr. Silverman is a paid consultant to Arcscan, Inc. No other author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Brian L. VanderBeek, MD, MPH, Weill Cor- nell Medical College, New York-Presbyterian Hospital, 1305 York Avenue, 11th Floor, New York, New York 10021, USA. E-mail: brian.vanderbeek@yahoo.com. Q 2009 ASCRS and ESCRS Published by Elsevier Inc. 0886-3350/09/$dsee front matter 785 doi:10.1016/j.jcrs.2008.09.033 CASE REPORT