Initial Treatment for Pinguecula
The initial treatment for pinguecula is artificial tears for minor irritation, with topical indomethacin 0.1% solution recommended for inflamed pinguecula causing significant symptoms. 1, 2
Understanding Pinguecula
Pinguecula is a benign, yellowish, slightly raised conjunctival nodule that typically appears at the nasal or temporal limbus of the eye. It consists of degenerated basophilic subepithelial tissue and is commonly associated with:
- UV light exposure
- Dust exposure
- Wind exposure
- Dry environments
Unlike pterygium, pinguecula does not grow onto the cornea and typically does not affect vision.
Treatment Algorithm
1. Asymptomatic Pinguecula
- No treatment required
- Patient education about UV protection (sunglasses)
- Avoidance of environmental irritants
2. Mildly Symptomatic Pinguecula
- Artificial tears for lubrication 1
- Preservative-free formulations preferred if frequent use is needed
- UV-blocking sunglasses when outdoors
3. Inflamed Pinguecula (Pingueculitis)
- Topical indomethacin 0.1% solution 4-6 times daily for 1-2 weeks 2
- Shown to significantly reduce signs and symptoms in a randomized controlled trial
- May cause mild stinging for less than 1 minute after administration
- Alternative: Topical corticosteroids (prednisolone acetate 1% four times daily for 1-2 weeks) 3
- Effective for reducing inflammation
- Should be limited to short courses due to potential side effects
4. Persistent Symptoms Despite Medical Therapy
- Consider surgical excision with conjunctival autograft using fibrin glue 4
- Shown to improve dry eye symptoms
- Indicated when pinguecula is at least twice as thick as adjacent normal conjunctiva
Clinical Assessment
When evaluating pinguecula:
- Measure size and elevation using slit lamp examination
- Consider anterior segment optical coherence tomography (AS-OCT) to quantify thickness 3
- Assess for associated dry eye symptoms
- Rule out other conjunctival lesions
Treatment Efficacy Monitoring
- Resolution of redness, irritation, and foreign body sensation
- Improvement in tear film break-up time (TBUT)
- Reduction in dry eye symptoms
- Decrease in size and thickness of the pinguecula on follow-up examination
Important Considerations
- Pinguecula may be associated with underlying conditions like Sjögren's syndrome in some cases 5
- Surgical excision should be reserved for cases that fail medical management or cause significant discomfort
- Patients with pinguecula often have concurrent dry eye syndrome that requires ongoing management
Pitfalls to Avoid
- Don't confuse pinguecula with pterygium (pterygium grows onto the cornea and may affect vision)
- Avoid prolonged use of topical steroids due to risk of increased intraocular pressure, cataract formation, and delayed wound healing
- Don't overlook underlying dry eye disease, which often coexists with pinguecula
- Surgical excision of asymptomatic pinguecula is not recommended as it may lead to scarring
By following this treatment approach, most patients with pinguecula can achieve symptomatic relief while minimizing the risk of complications.