H11.151-153 Pinguecula

A pinguecula appears as a yellow-white elevated, superficial mass on the surface of the eye.  Pinguecula are usually located in the interpalpebral fissure and they do not involve the cornea.  Although pinguecula are very common and usually benigh, they may be associated with chronic exposure keratoconjunctivitis.

A pinguecula consists of an abnormal degeneration of the collagen fibers in the conjunctival stroma.  There may be a thinning of the overlying conjunctival epithelium and some calcification within the body of the lesion.  Pinguecula are found bordering the limbus on either side of the bulbar conjunctiva.

		Age-Related Pinguecula Pinguecula may present in a variety of forms, but most are characterized by a nodular shape Pinguecula may enlarge slowly over time Most lesions are benign and do not require treatment Pinguecula that are irregularly-shaped and elevated tend to be age-related
Structural Damage to the Eye Severe pingueucula Normal pinguecula can become inflamed, a condition called pingueculitis  Pingueculitis can result in structural damage to the eye

Functional Damage to the Eye

• Reduced visual acuity secondary to corneal damage in exposure keratoconjunctivitis
• Reduced visual acuity secondary to ocular inflammation in severe pingueculitis

The main goal of the diagnostic evaluation is to accomplish the following:

• Determine the initiating insult(s)
• Classify the disease
• Prescribe a treatment program

Patient History

• Patient will come in and report a yellow “growth” on the surface of the eye
• If the patient has pingueculitis, they will come in with a red and irritated eye

Clinical Appearance of the Conjunctiva Pingueculitis secondary to contact lens wear Persistent ocular redness visible on face-to-face inspection Intrapalpebral conjunctival mass with a yellowish color Conjunctival punctate epithelial erosions

DIAGNOSTIC TESTS

External Ocular Photography

• Document size and shape of the pinguecula
• Document any damage to the cornea from the pinguecula
• Document any change in size and shape of the pinguecula
• Document any changes in the cornea
• Plan treatment of the pinguecula

Pinguecula can be classified by size, location, height, or etiology.  Once a pre-existing pinguecula becomes inflamed, the condition is called pingueculitis and is classified by the associated condition that causes the inflammation.

Type 0 – Normal Pinguecula

		Normal Pinguecula Small nodular-shaped pinguecula Mild elevation
		Normal Pinguecula Large nodular-shaped pinguecula Moderate elevation
		Normal Pinguecula Large diffuse pinguecula Gelatinous appearance

Type 1 – Pingueculitis secondary to abnormal lesion height or size

The most common initiating insult is mechanical irritation of the pinguecula 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. Since the eyelid margin has a significantly higher concentration of pain fibers than the conjunctiva, most patients will report the irritation as a foreign body sensation.

Mild pingueculitis

Same lesion 10 months earlier

Type 2 – Pingueculitis secondary to contact lens wear

If the pingueculitis is the result of a contact lens with a poor fitting relationship, discontinue contact lens wear, treat the inflamed pinguecula with lubrication and topical steroids, and if possible prescribe a contact lens with a different diameter or base curve.

Contact Lens-Induced Pingueculitis Conjunctival hyperemia surrounds the pinguecula The edge of the contact lens produces constant mechanical irritation on the pinguecula

Type 3 – Pingueculitis secondary to exposure to environmental irritants

Another common initiating insult to the pinguecula can be exposure to environmental irritants such as dust or debris. The chronic irritation draws inflammatory cells to the penguecula, and the inflammatory cascade begins.

Type 4 – Pingueculitis secondary to ocular surface disease

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 or pinguecula enlargement may occur. This type of pingueculitis has been implicated as a precursor of pterygium development.

Pinguecula Enlargement As Precursor to Pterygium Development The lesion has encroached onto the surface of the cornea Conjunctival epitheliopathy over the surface of the pinguecula Since there is no subepithelon is still referred to as a pinguecula

This would include any other disease that present as an interpalpebral conjunctival mass or elevation.  Lesions with this clinical apperance may also be a clinical sign of the following diseases or conditions:

• Episcleritis 
• Scleritis
• Conjunctival retention cyst
• Limbal follicle
• Pseudoepitheliomastous
• Conjunctival dermoid
• Chlamydial infection
• Chemical or thermal injury
• Cervical interepithelial neoplasm leading to squamous cell carcinoma

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 differential diagnoses.

Patients with a normal pinguecula can be observed.  If the pinguecula is small and stable, it is an option to leave it alone.  To reduce the chance of pinguecula enlargement, pingeuculitis or pterygium development doctors may recommend preventative treatment.

Preventative Treatment

• Decrease excessive exposure to wind and sunlight (UV)
• Aggressively treat any coexisting ocular surface disease
• Discontinue contact lens wear 
• Prescribe contact lenses that do not irritate a pre-existing pinguecula

Contact Lens Patient Patient with a good contact lens pinguecula relationship The contact lens edge does not touch the pinguecula

Pharmacologic Treatment

• Artificial tears
• Topical anti-inflammatory

		Pingueculitis Secondary to Environmental Exposure Day 1 presentation Remove the source of the environmental irritant (if possible) Treat the inflamed pinguecula with lubrication and topical steroids until the inflammation has resolved
		Resolving Pingueculitis Secondary Environmental Exposure Day 3 presentation Good compliance with Pred Forte 1% Ophthalmic Suspension Good compliance with Systane artificial tears
		Resolved Pingueculitis Day 8 presentation Good compliance with combination therapy Discontinue treatment

Surgical Treatment

Cosmetically Conspicuous Pinguecula Pinguecula can be surgically removed for cosmetic reasons Pinguecula removal is not a common procedure because of a high recurrence of the pinguecula Pinguecula can be removed to prevent recurrent pingueculitis, iridocyclitis or chronic exposure keratoconjunctivitis

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.