Things That Go Bump on the Cornea

Lumps and bumps on the corneal surface were discussed during one of the first presentations at ESCRS 2025, with the presenter noting she has been so successful in addressing these irregularities that some of her patients have elected to delay cataract surgery.

Nandini Venkateswaran MD kicked off Cornea Day by providing a comprehensive overview of things that can ‘go bump’ on the cornea. Describing case studies on patients affected by Salzmann’s nodules, pterygia, and epithelial basement membrane dystrophy (EBMD), Dr Venkateswaran’s enthusiasm for the topic was apparent.

“The question is, how do we proceed? Do we do cataract surgery; do we address the Salzmann’s nodule?” Dr Venkateswaran asked. “Corneal irregularities, which I like to refer to as lumps and bumps, determine how we proceed with surgery, which is why it’s important to optimise the corneal surface before proceeding.”

To that point, Dr Venkateswaran described a 68-year-old female patient presenting for cataract surgery with Salzmann’s nodules and nuclear sclerosis lasting for more than two years. After a superficial keratectomy was performed, she experienced a drop of 2.0 D in corneal astigmatism; after the nodule was removed, she was able to enjoy BCVA of 20/20.

“I’m almost putting myself out of business,” Dr Venkateswaran said. “For the last five years, she’s been so happy with her vision after the removal of the nodule that she continues to defer cataract surgery.

“Considerations for Salzmann’s nodules are so underrated. I think it’s really important to address them,” she said. “You can remove them with a superficial keratectomy and a nodulectomy. Consider a diamond burr or phototherapeutic keratectomy (PTK) to reduce scarring.”

When it comes to pterygia, Dr Venkateswaran pointed to her treatment of a 60-year-old female patient with a combined cataract and significant pterygium lasting more than two years. She “took biometric measurements,” the results of which recommended an 18.0 D monofocal lens. Topographic images found irregular astigmatism at nearly 6.0 D with marked flattening of the nasal cornea.

“In a scenario like this, I would advocate for removal of the pterygium, given how much of an effect it’s having on the corneal surface,” Dr Venkateswaran said. “I like to remove pterygia in the operating room, spending time to do a nice, clean dissection. I spend time at the head of the pterygium to ensure that I can really improve the corneal architecture and surface.”

Finally, regarding EBMD, Dr Venkateswaran recommends performing a superficial keratectomy if the disease is present in the central 3 mm to 4 mm of the cornea, especially if it’s causing vision fluctuation and irregular astigmatism. She also recommends diamond burr polishing and PTK if there is “a recurrent erosion component or subepithelial ridges.”

“EBMD can induce a great degree of irregular astigmatism,” she said. “Similarly to my Salzmann’s nodule cases, I’d like to wait 8 to 12 weeks to allow for re-epithelialisation and normalisation of the cornea.”

Nandini Venkateswaran MD is an associate professor of ophthalmology at Harvard University Medical School, Massachusetts, US.