Pinguecula

Aetiology

Degenerative conjunctival lesion, usually situated horizontally at the limbus
Degeneration of collagen fibres of the conjunctival stroma

• hyalinisation of sub-epithelial collagen
• elastotic degeneration
• 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
A population-based study from Spain showed a strong correlation with alcohol intake

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
• 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

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
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=low, Strength of recommendation=strong)

Pingueculitis usually responds to a brief course of a ‘non-penetrating’ topical steroid (e.g. fluorometholone, loteprednol) or a topical non-steroidal anti-inflammatory drug (off-licence use)
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)
(GRADE*: Level of evidence=moderate, Strength of recommendation=weak)

Management category

B2: alleviation / palliation: normally no referral

Possible management by ophthalmologist

Excision is very rarely warranted
Case series have described effective cosmetic removed of pingueculae by argon laser photocoagulation and by surgical excision with free conjunctival autografting

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

Jung S, Kwon JW, Hwang HS, Chuck RS. Vascular Regression After Pinguecula Excision and Conjunctival Autograft Using Fibrin Glue. Eye Contact Lens. 2017;43(3):199-202

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

Mimura T, Usui T, Obata H, Yamagami S, Mori M, Funatsu H, Noma H, Dou K, Amano S., Oguz H, Karadede S, Bitiren M, Gurler B, Cakmak M. Severity and determinants of pinguecula in a hospital-based population. Eye Contact Lens. 2011;37(1):31-5

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

Plain language 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 7
Date of search 16.12.19
Date of revision 20.12.19
Date of publication 23.07.21
Date for review 15.12.21
© College of Optometrists

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