Relationship of Bell phenomenon with Salzmann nodular degeneration

To determine the relationship of Bell phenomenon with the presence and the location of Salzmann nodular degeneration.

This is a noninterventional observational case series study. We reviewed the medical records of 10 patients with Salzmann nodules between 2001 and 2012. The mean age of participants was 60 years with 8 women and 2 men. A complete history and eye examination was performed with regular follow-up visits to document the progression of the disease. The data collected were as follows: age, gender, Snellen visual acuity, manifest refraction, Salzmann nodule location, presence of Bell or inverse Bell phenomenon, treatment, and associated conditions. Slit-lamp pictures to document the location of the Salzmann nodules and the direction of the Bell phenomenon were obtained.

Five patients had inferior Salzmann nodules with a normal Bell phenomenon and 5 patients had superior nodules with inverse Bell phenomenon. Nine of 10 patients had moderate to severe meibomian gland disease and dry eye syndrome as associated conditions. Two of the patients underwent removal of the nodules with lamellar keratectomy and 1 with phototherapeutic keratectomy, all with mitomycin-C application and without recurrence of the nodules at 1 year of follow-up.

In all 10 patients the direction of the globe rotation during a normal or inverse Bell phenomenon was directly correlated to the location of the Salzmann nodules. Specifically, patients with inverse Bell phenomenon presented with superior nodule formation, whereas patients with a normal Bell phenomenon presented with inferior nodules.