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CLINICAL MANAGEMENT GUIDELINES
Pinguecula
Aetiology
Degenerative conjunctival lesion, usually situated nasally at the limbus
Degeneration of collagen fibres of the conjunctival stroma
• hyalinisation and granular deposits
• thinning of overlying epithelium
• occasional calcification
Predisposing factors Increasing age (seen in most eyes by age 70)
Published figures of prevalence range from 11-75% (prevalence depends
on age and geographical location of the sample)
Long term exposure to UV radiation
• sunlight (equatorial residence [37° either side of the equator],
outdoor work, especially on reflective surfaces e.g. sand,
concrete, water, snow)
• welding and other occupational exposure
Male gender (likely to be related to occupational exposure)
Chronic irritation from wind or dust
Contact lens wear
Symptoms
Usually asymptomatic
Possible mild foreign body sensation and redness when inflamed
Occasional cosmetic concern
Signs
Area of conjunctival thickening adjoining the limbus
• in the palpebral aperture, usually at 3 & 9 o’clock positions
• more common nasally
• usually bilateral
Elevated and less transparent than normal conjunctiva
White to yellow colour, fat like appearance, calcification sometimes
present
Sometimes slightly more hyperaemic than surrounding conjunctiva
May become inflamed (pingueculitis) causing mild ocular irritation
May lead to Dellen in adjacent cornea
Decreased TBUT
Differential diagnosis Pterygium
• easily distinguished because pinguecula does not cross the
limbus to involve the cornea
• pinguecula does not progress to become pterygium; they are two
distinct conditions
Conjunctival intraepithelial neoplasia (can resemble a keratinised
pinguecula)
Dermoid cyst
Epithelial retention cyst (thin-walled lesion containing clear fluid)
Differentiate from inflammatory conditions, e.g. episcleritis, angular
conjunctivitis
Management by Optometrist
Practitioners should recognise their limitations and where necessary seek further advice or refer
the patient elsewhere
Non pharmacological
Reassure patient about benign nature of the lesion (no threat to health or
sight)
Advise on UV protection to minimise risk of inflammation
•
brimmed hat, sunglasses in wrap-around style for side
protection
Cold compresses when inflamed
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Pharmacological
Ocular lubricants for symptomatic relief (drops for use during the day,
Pinguecula
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Date of search 12.11.15; Date of revision 24.02.16; Date of publication 29.03.16; Date for review 11.11.17
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Pinguecula
unmedicated ointment for use at bedtime
NB Patients on long-term medication may develop sensitivity reactions
which may be to active ingredients or to preservative systems (see
Guideline on Conjunctivitis Medicamentosa). They should be switched to
unpreserved preparations
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Pingueculitis usually responds to a brief course of a ‘non-penetrating’
topical steroid (e.g. fluorometholone, rimexolone, loteprednol) or a topical
non-steroidal drug
NB All patients on topical steroid drops or ointment should have their
intraocular pressures checked initially, then measured again at 2 weeks
and every 4 weeks for 2-3 months (see Clinical Management Guideline
on Steroid Glaucoma)
(GRADE*: Level of evidence=moderate, Strength of recommendation=weak)
Management Category B2: Alleviation / palliation: normally no referral
Possible management by Ophthalmologist
Excision is very rarely warranted
A single case series has described effective cosmetic removed of
pingueculae by argon laser photocoagulation
Evidence base
*GRADE: Grading of Recommendations Assessment, Development and
Evaluation (see http://gradeworkinggroup.org/toolbox/index.htm)
Sources of evidence
Ahn SJ, Shin KH, Kim MK, Wee WR, Kwon JW. One-Year Outcome of
Argon laser photocoagulation of pinguecula. Cornea. 2013;32:971-5
Frucht-Pery J, Siganos CS, Solomon A, Shvartzenberg T, Richard C,
Trinquand C. Treatment of inflamed pterygium and pinguecula with
topical indomethacin 0.1% solution. Cornea. 1997;16:42-7
Frucht-Pery J, Siganos CS, Solomon A, Shvartzenberg T, Richard C,
Trinquand C. Topical indomethacin solution versus dexamethasone
solution for treatment of inflamed pterygium and pinguecula: a
prospective randomized clinical study. Am J Ophthalmol.
1999;127(2):148-52
Mimura T, Usui T, Mori M, Yamamoto H, Obata H, Yamagami S, Funatsu
H, Noma H, Honda N, Amano S. Pinguecula and contact lenses. Eye
(Lond). 2010;24(11):1685-91
Oguz H, Karadede S, Bitiren M, Gurler B, Cakmak M. Tear functions in
patients with pinguecula. Acta Ophthalmol Scand. 2001;79(3):262-5
Viso E, Gude F, Rodríguez-Ares MT. Prevalence of pinguecula and
pterygium in a general population in Spain. Eye (Lond). 2011;25(3):350-7
LAY SUMMARY
A pinguecula is a small raised spot, white to yellowish in colour, that sometimes appears on the
surface of the eye at the limbus. The limbus is where the white of the eye (the sclera) and the
transparent window at the front of the eye (the cornea) meet. If the cornea is imagined as a clock
Pinguecula
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Date of search 12.11.15; Date of revision 24.02.16; Date of publication 29.03.16; Date for review 11.11.17
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Pinguecula
face, a pinguecula will generally form at the three and nine o’clock positions. This condition
becomes commoner as people age, so that by 70 years most people have them. Both eyes are
usually affected. There is no effect on vision.
This is a mild degenerative condition, due to long-term exposure to ultra-violet (UV) light, either
occurring naturally in sunlight or artificially in some occupations. A pinguecula usually causes no
symptoms, but if it becomes inflamed it may cause local redness of the eye and irritation or
discomfort. Sometimes people complain of the cosmetic appearance.
The optometrist will examine the pinguecula carefully, distinguishing it from other small spots and
cysts that sometimes appear on the eye surface in this position. Once the diagnosis is made, the
patient will be advised to limit UV exposure by wearing a hat and sunglasses when it is sunny. If
the pinguecula becomes inflamed, anti-inflammatory eye drops are sometimes recommended.
Sometimes patients ask for a pinguecula to be removed, which can be done by surgery or laser
treatment. As this is nearly always a cosmetic procedure, it is rarely undertaken.
Pinguecula
Version 5, Page 3 of 3
Date of search 12.11.15; Date of revision 24.02.16; Date of publication 29.03.16; Date for review 11.11.17
© College of Optometrists