Pinguecula

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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Aetiology

  • Degenerative conjunctival lesion, usually situated nasally at the limbus
  • Degeneration of collagen fibres of the conjunctival stroma
    • hyalinisation and granular deposits
    • thinning of overlying epithelium
    • occasional calcification

Predisposing factors

  • Increasing age (seen in most eyes by age 70)
  • Published figures of prevalence range from 11-75% (prevalence depends on age and geographical location of the sample)
  • Long term exposure to UV radiation
    • sunlight (residence at or near the equator, outdoor work, especially on reflective surfaces e.g. sand, concrete, water, snow)
    • welding and other occupational exposure
  • Male gender (likely to be related to occupational exposure)
  • Chronic irritation from wind or dust
  • Contact lens wear

Symptoms

  • Usually asymptomatic
  • Possible mild foreign body sensation and redness when inflamed
  • Occasional cosmetic concern

Signs

  • Area of conjunctival thickening adjoining the limbus
    • in the palpebral aperture, usually at 3 & 9 o’clock positions
    • more common nasally
    • usually bilateral
  • Elevated and less transparent than normal conjunctiva
  • White to yellow colour, fat like appearance, calcification sometimes present
  • Sometimes slightly more hyperaemic than surrounding conjunctiva
  • May become inflamed (pingueculitis) causing mild ocular irritation
  • May lead to Dellen in adjacent cornea
  • Decreased TBUT

Differential diagnosis

  • Pterygium
    • easily distinguished because pinguecula does not cross the limbus to involve the cornea
    • pinguecula does not progress to become pterygium; they are two distinct conditions
  • Conjunctival intraepithelial neoplasia (can resemble a keratinised pinguecula)
  • Dermoid cyst
  • Epithelial retention cyst (thin-walled lesion containing clear fluid)
  • Differentiate from inflammatory conditions, e.g. episcleritis, angular conjunctivitis

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

GRADE Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Non pharmacological
  • Reassure patient about benign nature of the lesion (no threat to health or sight)
  • Advise on UV protection to minimise risk of inflammation
    • brimmed hat, sunglasses in wrap-around style for side protection
  • Cold compresses when inflamed

(GRADE*: Level of evidence=low, Strength of recommendation=strong)
 

Pharmacological
  • Ocular lubricants for symptomatic relief (drops for use during the day, unmedicated ointment for use at bedtime

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

NB Patients on long-term medication may develop sensitivity reactions which may be to active ingredients or to preservative systems (see Guideline on Conjunctivitis Medicamentosa). They should be switched to unpreserved preparations

(GRADE*: Level of evidence=moderate, Strength of recommendation=weak)

NB All patients on topical steroid drops or ointment should have their intraocular pressures checked initially, then measured again at 2 weeks and every 4 weeks for 2-3 months (see Clinical Management Guideline on Steroid Glaucoma)

Management category

B2: alleviation / palliation: normally no referral

Possible management by ophthalmologist

  • Excision is very rarely warranted
  • A single case series has described effective cosmetic removed of pingueculae by argon laser photocoagulation

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup.org)
 

Sources of evidence

Ahn SJ, Shin KH, Kim MK, Wee WR, Kwon JW. One-Year Outcome of Argon laser photocoagulation of pinguecula. Cornea. 2013;32:971-5

Frucht-Pery J, Siganos CS, Solomon A, Shvartzenberg T, Richard C, Trinquand C. Treatment of inflamed pterygium and pinguecula with topical indomethacin 0.1% solution. Cornea. 1997;16:42-7

Frucht-Pery J, Siganos CS, Solomon A, Shvartzenberg T, Richard C, Trinquand C. Topical indomethacin solution versus dexamethasone solution for treatment of inflamed pterygium and pinguecula: a prospective randomized clinical study. Am J Ophthalmol. 1999;127(2):148-52

Mimura T, Usui T, Mori M, Yamamoto H, Obata H, Yamagami S, Funatsu H, Noma H, Honda N, Amano S. Pinguecula and contact lenses. Eye (Lond). 2010;24(11):1685-91

Oguz H, Karadede S, Bitiren M, Gurler B, Cakmak M. Tear functions in patients with pinguecula. Acta Ophthalmol Scand. 2001;79(3):262-5

Viso E, Gude F, Rodríguez-Ares MT. Prevalence of pinguecula and pterygium in a general population in Spain. Eye (Lond). 2011;25(3):350-7

Lay summary

A pinguecula is a small raised spot, white to yellowish in colour, that sometimes appears on the surface of the eye at the limbus. The limbus is where the white of the eye (the sclera) and the transparent window at the front of the eye (the cornea) meet. If the cornea is imagined as a clock face, a pinguecula will generally form at the three and nine o’clock positions. This condition becomes commoner as people age, so that by 70 years most people have them. Both eyes are usually affected. There is no effect on vision.

This is a mild degenerative condition, due to long-term exposure to ultra-violet (UV) light, either occurring naturally in sunlight or artificially in some occupations. A pinguecula usually causes no symptoms, but if it becomes inflamed it may cause local redness of the eye and irritation or discomfort. Sometimes people complain of the cosmetic appearance.

The optometrist will examine the pinguecula carefully, distinguishing it from other small spots and cysts that sometimes appear on the eye surface in this position. Once the diagnosis is made, the patient will be advised to limit UV exposure by wearing a hat and sunglasses when it is sunny. If the pinguecula becomes inflamed, anti-inflammatory eye drops are sometimes recommended. Sometimes patients ask for a pinguecula to be removed, which can be done by surgery or laser treatment. As this is nearly always a cosmetic procedure, it is rarely undertaken.

Pinguecula
Version 6
Date of search 17.11.17
Date of revision 29.03.18
Date of publication 09.05.18
Date for review 16.11.19
© College of Optometrists

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