Pingueculitis

A 52-year-old male, who had previously been diagnosed with dry eye, meibomian gland dysfunction, pingueculae, and grade 1 nuclear sclerosis, presented to our clinic with a history of recent-onset irritation and redness in his left eye. He had successfully worn soft contact lenses on a daily wear schedule for many years. The patient denied any significant recent or past ocular trauma.

Presenting corrected visual acuities were 20/20 OD and OS. Biomicroscopy revealed an elevated, injected conjunctival lesion encroaching on the limbus of the left eye but not in contact with the contact lens. The lesion stained with sodium fluorescein. Our initial diagnosis was inflammation of a previously diagnosed pinguecula.

Pingueculae and pterygia are peribulbar conjunctival lesions that, although often similar in appearance, are distinctly different in prognosis and management.¹ The histology of these conditions and their potential for complications are significantly different. Pingueculae are well-formed nodular lesions, but pterygia present with stromal fibrosis, neovascularization, vascular congestion, and, in some cases, chronic inflammation.¹

Both conditions are considered non-neoplastic, ultraviolet-light-related pathologies.¹ Pterygia may encroach upon the visual axis and, in some cases, require surgical intervention, whereas pingueculae typically do not present a threat to vision or invade the cornea.^1,2 Ultraviolet light exposure, increasing age, male gender, diabetes mellitus, and ocular dryness have been identified as risk factors for the development of pingueculae.²

In some individuals, such as our patient, pingueculae may become inflamed. In a two-site Turkish study, Küçük et al evaluated the ocular surface of 32 individuals who presented with symptomatic, inflamed pingueculae.² They defined inflamed as ”a combination of vascular congestion and hyperemia of the pinguecula and adjacent conjunctiva in biomicroscopic examination together with patients’ description of a recent increase in ocular redness and one or more of the following symptoms: photophobia, pain, foreign-body sensation, discomfort, and tearing.”² Inflamed pingueculae have been associated with an impaired corneal epithelium a well as with alterations in tear film parameters. This raises the question of whether dryness causes inflammation in an existing pinguecula or whether the pinguecula leads to dryness.

The authors postulated that an abnormality of the tear film, specifically dryness, precedes the onset of pinguecula inflammation. They also proposed that impaired tear film together with mechanical irritation of this elevated tissue makes pingueculae prone to inflammation.²

Linaburg et al performed a literature review to evaluate the relationship between ocular surface disease and the presence of pterygium or pinguecula.³ They found that in most studies, when compared with controls, eyes that had these conditions had a statistically significantly lower tear breakup time, lower Schirmer I and Schirmer II scores, higher tear osmolarity, and higher Ocular Surface Disease Index scores. Their findings suggest a strong association between the presence of pterygia or pinguecula and ocular surface disease.

In the case of our patient, we prescribed a topical steroid and frequent instillation of non-preserved artificial tears; this ultimately led to resolution of the condition.

References

1. Mudhar HS. Update on conjunctival pathology. Indian J Ophthalmol. 2017 Sep;65:797-807.
2. Küçük E, Yılmaz U, Zor KR. Corneal Epithelial Damage and Impaired Tear Functions in Patients with Inflamed Pinguecula. J Ophthalmol. 2018 Oct 31;2018:2474173.
3. Linaburg T, Choi D, Bunya VY, Massaro-Giordano M, Briceño CA. Systematic Review: Effects of Pterygium and Pingueculum on the Ocular Surface and Efficacy of Surgical Excision. Cornea. 2021 Feb 1;40:258-267.