Pinguecula

A pinguecula is a benign yellow white, slightly raised, triangular conjunctival degeneration on the nasal or temporal bulbar conjunctiva adjacent to the limbus within the interpalpebral fissure, without invading the cornea.

• It results from elastotic degeneration of collagen in the substantia propria, caused by chronic ultraviolet light exposure, wind, dust, and dryness; common after age 30, nearly universal by old age in sunny climates.
• It differs from pterygium by not crossing the limbus onto the cornea; a pinguecula can progress to a pterygium.
• Pingueculitis is an acute inflammation of the lesion.

• Usually asymptomatic with cosmetic concern, or mild foreign body sensation, dryness, and redness.
• Flat or slightly elevated yellowish nodule, avascular or with minimal vessels, sometimes with calcification, often bilateral and nasal.
• Inflamed lesions: localised hyperaemia, tenderness, and secondary tear film disruption with dellen formation (corneal thinning adjacent to the lesion from poor lubrication).
• Contact lens intolerance.

• Slit lamp examination; no investigation is needed in typical cases.
• Exclude conjunctival neoplasia (ocular surface squamous neoplasia, melanoma, lymphoma) if the lesion is growing, pigmented, vascular, leukoplakic, or fleshy, and perform excision biopsy for histology.
• Differential diagnosis: pterygium, phlyctenule, episcleritis, foreign body granuloma, conjunctival cyst, and Bitot spots.

• Reassurance, UV-protective sunglasses with side shields, and hats.
• Preservative free lubricants four to six times daily.
• Pingueculitis: short topical corticosteroid, fluorometholone 0.1 percent or loteprednol 0.5 percent four times daily for 1 to 2 weeks, or a topical NSAID (ketorolac 0.5 percent or diclofenac 0.1 percent) four times daily for 1 to 2 weeks; cold compresses; avoid long vasoconstrictor use.
• Dellen: lubricating ointment and temporary patching or a bandage lens.
• Surgery indicated for recurrent inflammation, cosmetic concern, contact lens intolerance, or suspicion of neoplasia: simple excision with or without conjunctival autograft or amniotic membrane, with intraoperative mitomycin C not needed. Recurrence is possible if the elastotic tissue is incompletely removed.
• Review annually or sooner if the lesion changes.