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 Increasing age (seen in most eyes by age 70) Long term exposure to UV radiation sunlight (equatorial residence. outdoor work, especially on reflective surfaces eg sand, concrete, water, snow) welding and other occupational exposure Chronic irritation from wind or dust Usually asymptomatic Possible mild foreign body sensation and redness when inflamed Occasional cosmetic concern Area of conjunctival thickening adjoining the limbus in the palpebral aperture, usually at 3 & 9 oclock 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

Predisposing factors

Symptoms

Signs

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 Retention cyst (thin-walled lesion containing clear fluid) Differentiate from inflammatory conditions, eg 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 Pharmacological Ocular lubricants for symptomatic relief (drops for use during the day, 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
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CLINICAL MANAGEMENT GUIDELINES

Pinguecula
Pingueculitis usually responds to a brief course of a non-penetrating topical steroid (eg 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) Management Category B2: Alleviation / palliation: normally no referral Possible management by Ophthalmologist Excision is very rarely warranted Evidence base Frucht-Pery J et al.: 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 Authors conclusion: topical indomethacin 0.1% solution is as effective as topical dexamethasone 0.1% solution for the treatment of inflamed pterygium and pinguecula (The Oxford 2011 Levels of Evidence = 2)

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