H10.811-813 Pingueculitis

Pingueculitis is an inflammation of a pre-existing pinguecula.  A pinguecula is a type of conjunctival degeneration that forms as a result of an elastic and collagen degenerative process.  Pinguecula formation is believed to be precipated by ultraviolet light and environmental exposure.  Advancing age is also a risk factor in the development of a pinguecula.

The images below present a normal pinguecula upon initial examination and again 10 months later during an episode of pingueculitis:

There are several types of initiating insults that result in pingueculitis.

Mechanical irritation by the eyelids during the blink mechanism

• This mechanical irritation occurs when the pinguecula becomes abnormally elevated or abnormally sized, and the eyelids have trouble moving over the lesion.

Improperly fitting contact lenses

• This occurs when the diameter of the contact lens is not appropriate for the size or location of the pingeucula and the edge of the contact lens irritates the lesion.

Exposure to environmental irritants

• UV radiation and environmental irritants such as dust or debris produce chronic irritation that draws inflammatory cells to the pinguecula, and the inflammatory response begins.

Ocular surface disease

Moderately severe dry eye syndrome and chronic ocular allergy can produce chemical irritation and structural damage to the ocular surface.  When this irritation and damage is localized on or around a pre-existing pinguecula, pingueculitis may result.

Structural Damage to the Eye Normal pinguecula can become inflamed Severe pingueculitis can produce an inflammatory response in the anterior segment of the eye Functional Damage to the Eye Reduced visual acuity secondary to corneal damage in exposure keratoconjunctivitis Reduced visual acuity secondary to anterior uveitis in severe pingueculitis

The main goal of the diagnostic evaluation of a patient with pingueculitis is to accomplish the following:

• Determine the initiating insult
• Classify the disease
• Prescribe a treatment plan

Patient History

Patients with pingueculitis will usually present with the following signs and symptoms.

• Red eye
• Ocular discomfort

Clinical Appearance of the Conjunctiva

• Interpalpebral conjunctival mass or lesion
• Localized conjunctival hyperemia
• Exposure keratoconjunctivitis
• Punctate epithelial erosions of the conjunctival epithelium
• Corneal delle

		Pingueculitis Conspicuous conjunctival hyperemia surrounds the pinguecula Clinical diagnosis can sometimes be made with a face-to-face examination
		Pingueculitis Contact lens-induced pingueculitis Abnormally large pinguecula Poor pinguecula location for soft contact wear
Pingueculitis Abnormally elevated pinguecula becomes irritated by the blink mechanism of the eyelids Mechanical damage to the conjunctival epithelial cells at the apex of the pinguecula is revealed with lissamine green staining No conjunctival hyperemia
Exposure Keratoconjunctivitis Abnormally large pinguecula Size of the pinguecula prevents the eyelids from wetting the conjunctiva at the base of the pinguecula Exposure-related damage to the conjunctival epithelial cells at the base of the pinguecula is revealed with lissamine green staining No conjunctival hyperemia
Corneal Delle A corneal delle is a form of exposure keratoconjunctivitis It represents an area of localized corneal thinning Delle formation is characterized by a small depression in the corneal periphery The depressions produced when the stroma loses water The loss of water is caused by improper wetting of the corneal surface by the tear film In pinguecula-induced corneal delle, improper corneal wetting is caused by an abnormally large or elevated pinguecula being located directly adjacent to the limbus The large or elevated pinguecula can prevent the eyelid from wetting the corneal surface with a blink

DIAGNOSTIC TESTS

External Ocular Photography

• Document the size and shape of the pinguecula
• Document any damage to the ocular surface from the pinguecula
• Document any changes in size and shape of the pinguecula
• Document any changes in the cornea or conjunctiva
• Help develop a treatment plan

Day 1 – Steroid treatment initiated

Day 3 – Pingueculitis improving

Day 8 – Pingueculitis resolved

Pingueculitis is classified based upon its initiating insult. 

• Abnormal pinguecula height or size
• Improperly fitted contact lenses
• Exposure to environmental irritants
• Ocular surface disease

This would include any other disease that presents as an interpalpebral conjunctival mass or elevation.  Conjunctival lesions with this clinical appearance may be also a clinical sign of the following diseases or conditions.  If conjunctival hyperemia is present, the location of the hyperemia, its time of onset, the severity of any ocular discomfort, and the determination of an initiating insult are all important factors to consider when excluding any of the following differential diagnoses.

• Episcleritis
• Scleritis
• Conjunctival retension cyst
• Limbal follicle
• Pseudoepitheliomastous hyperplasia
• Conjunctival intraepithelial neoplasia
• Conjunctvial dermoid
• Chlamydial infection
• Chemical or thermal injury

The treatment of pingueculitis is determined by the etiology of the disease.  Because pingueculitis is an inflammatory condition, topical anti-inflammatory medication will usually hasten the resolution of patient symptoms and clinical signs.

1.  Abelson MB, Mertz P. Pingueculitis:  how to keep your patients safe from this condition.  Review of Cornea & Contact Lenses. Sept. 2006: 8.
2.  Pingueculitis.  RevOptom.  Handbook of ocular disease management. http://legacy.revoptom.com/handbook/sect2h.htm.  Last accessed March 31, 2014.
3.  Prince M.  Pingueculitis A.K.A. “Inflamed Pinguecula.”  http://myeyepod.blogspot.com/2011/04/pingueculitis-aka- inflamed-pinguecula.html.  Last accessed March 31, 2014.
4.  Fisher J.  Pterygium.  Medscape. 17 April 2013.  http://emedicine.medscape.com/article/1192527- overview#a0199.  Last accessed July 22, 2014.