Pingueculitis

Pingueculitis is inflammation of a pinguecula, a yellowish white raised degenerative conjunctival nodule on the bulbar conjunctiva at the nasal or temporal limbus, caused by chronic exposure to ultraviolet light, wind and dust. A pinguecula is very common (present in more than half of adults over 50) and is usually harmless, but it can become acutely red, swollen and irritated. It differs from a pterygium in that it does not extend onto the cornea.

• Pinguecula: elastotic degeneration of collagen in the conjunctival stroma.
• Triggers for inflammation: dryness, wind, smoke, sunlight, contact lens wear, rubbing, allergy, blepharitis, trauma, hormonal changes.
• Usually mild, self-limited, and recurrent; about 1 in 5 patients with a pinguecula experience episodes.
• Complications: chronic irritation, dellen (corneal thinning adjacent to an elevated nodule), cosmetic concern, interference with contact lens fit.

• Localised redness at the interpalpebral bulbar conjunctiva, a sensation of grittiness or a foreign body, burning, mild discomfort, tearing, cosmetic concern; no discharge, no marked pain, vision is normal.
• Examination: a yellowish white, raised, triangular nodule at the nasal (commonest) or temporal limbus, with surrounding hyperaemia and fine vessels; the cornea is clear; the nodule does not cross the limbus.
• Red flags: nodule extending onto the cornea (pterygium), pain on eye movement or deep boring pain (scleritis), photophobia, vision loss, discharge, pigmented or fleshy vascular lesion with rapid growth (conjunctival neoplasia such as ocular surface squamous neoplasia or melanoma), non-resolving after 2 to 3 weeks, recurrent inflammation, corneal thinning, history of ocular surface disease.

• Clinical, by slit lamp examination.
• Topical phenylephrine 2.5 percent test: conjunctival and episcleral vessels blanch, which helps distinguish pingueculitis and episcleritis from scleritis (deep vessels do not blanch).
• Fluorescein staining for dellen or corneal involvement.
• Biopsy for suspicious, rapidly growing, pigmented or vascular lesions.
• Differentials: episcleritis, scleritis, pterygium, phlyctenule, conjunctivitis, foreign body, conjunctival cyst, ocular surface squamous neoplasia, melanoma, Salzmann nodule.

• Reassure that it is benign. Protect from sun, wind and dust with wrap around UV400 sunglasses; avoid rubbing; stop contact lens wear during the flare.
• Lubricants: preservative free carmellose 0.5 percent or sodium hyaluronate 0.1 percent, 4 to 6 times daily, with a lubricating ointment at night in dellen; cold compresses.
• Topical anti-inflammatory therapy for symptomatic episodes:
  • Topical NSAID such as ketorolac 0.5 percent or diclofenac 0.1 percent, 1 drop four times daily for 1 to 2 weeks (may sting).
  • Low potency steroid: fluorometholone 0.1 percent or loteprednol 0.5 percent, 1 drop four times daily for 5 to 7 days, then tapered over a week (prescribed by an eye specialist, with intraocular pressure monitoring if used beyond 2 weeks).
  • Antihistamine and mast cell stabiliser drops (olopatadine 0.1 percent twice daily) if allergic.
• Avoid chronic steroid use.
• Surgical excision (with or without conjunctival graft or amniotic membrane) for persistent inflammation, dellen, contact lens intolerance or cosmesis; recurrence is possible.
• Review in 1 to 2 weeks; refer for failure to respond, recurrent episodes, corneal involvement, or suspicious features.