Pinguecula

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Article initiated by:

Saba Al-Hashimi, MD

All contributors:

Saba Al-Hashimi, MD, Vatinee Y. Bunya, MD, MSCE, Maria A. Woodward, MD, Colleen Halfpenny, M.D.

Assigned editor:

Colleen Halfpenny, M.D.

Review:

Assigned status Update Pending

 by Colleen Halfpenny, M.D. on May 27, 2024.

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Contributing Editors:	add

Pinguecula

Raised fleshy appearing lesion near the limbus

DiseasesDB

10046

ICD-10

H11.1

ICD-9

372.51

MeSH

D059407

Pinguecula, plural pingueculae

Derived from the Latin word "pinguis" which means fat or grease

ICD-9 Code 372.51

Disease Entity

A relatively common non-malignant, raised yellow-white lesion of the interpalpebral bulbar conjunctiva that does not involve the cornea and represents elastoic degeneration of subepithelial collagen with hyalinized connective tissue. These fleshy lesions are typically found bilaterally and adjacent to the limbus of the nasal bulbar conjunctiva although they can be present temporally as well.

Etiology

Pingueculae are thought to arise as a result of the effects of environmental irritants such as wind and dust and are associated with UV-light exposure and aging, however the evidence of the association between UV-light exposure and pingueculae remains limited. It is thought that both pteryigia and pingueculae arise more commonly on the nasal side because light passing medially through the cornea focuses on the area of the nasal limbus while the shadow of the nose reduces the intensity of light transmitted to the area of the temporal limbus.

Risk Factors

UV-light exposure, wind, dust, outdoor lifestyle and proximity to the equator. age, male gender, smoking, working outdoors, diabetes mellitus

General Histopathology

The finding of increased nuclear p53 in the limbal epithelium of pterygia, limbal tumors, and most pingueculae indicates the probable existence of p53 mutations in these cells as an early event in their development, which is consistent with their causation by UV radiation exposure. Verhoeff elastic stain demonstrates degeneration of the elastoic tissue (stains for elastin but is not broken down by elastase) of subepithelial stromal collagen with hyalinized connective tissue. The overlying epithelium is often thinned but may be hyperplastic or dysplastic.

Primary prevention

Avoidance of UV-light exposure may decrease the incidence.

Diagnosis

The diagnosis is usually made clinically by slit-lamp biomicroscopy. The classic growth is raised and yellow-white in color, found in the interpalpebral fissure and is more common nasally than temporally. The lesion may be highly vascularized and injected or associated with punctuate epithelial erosions or dellen (thinning of adjacent cornea due to drying).

Physical examination

See diagnosis

Signs

See diagnosis

Symptoms

Most pingueculae are asymptomatic but may cause ocular surface irritation including foreign body sensation, tearing, burning or itching. Some may find these lesions cosmetically unacceptable.

Diagnostic procedures

Biopsy with histopathologic confirmation is not usually necessary but may be indicated for atypical cases where the diagnosis remains questionable. The thickness of the lesion can be monitored with anterior segment OCT.

Laboratory test

Not indicated

Differential diagnosis

• Conjunctival intraepithelial neoplasia (CIN)
• Limbal dermoid
• Conjunctival tumor (e.g., papilloma, nevus, melanoma)

Management

Lubrication with artificial tears and ointment can help with ocular surface irritation. Excision is indicated only when pingueculae are cosmetically unacceptable or when they become chronically inflamed or interfere with successful contact lens wear. Long-term use of topical steroid therapy should be discouraged due to adverse side-effects but can but used judiciously in patients with inflamed pingeuculae termed “pingueculitis”. Topical indomethicin has also been demonstrated at reducing symptoms of inflammation.

Surgery

Laser photocoagulation and surgical excision of pingueculae have both been used successfully with similar cosmetic outcomes.

A study of 30 patients showed surgical excision of symptomatic pinguecula with conjunctival autograft secured with fibrin glue improved not only cosmesis but also improved dry eye syndrome.

Prognosis

Pingculae may grow slowly over time but are associated with minimal ocular morbidity.

One study showed that nasal corneal epithelial damage in inflamed pinguecula patients may be a stimulus for exaggerated wound repair causing the release of growth factors leading to growth of conjunctival epithelium onto the cornea. Inflamed pinguecula patients with impaired ocular surface lubrication and nasal corneal epithelial defects may be a subgroup of pinguecula patients who have a propensity to progress to pterygium.

Additional Resources

• Boyd K, Lipsky SN. Pinguecula and Pterygium. American Academy of Ophthalmology. EyeSmart/Eye health. https://www.aao.org/eye-health/diseases/pinguecula-pterygium-list. Accessed March 21, 2019.