Treatment and Management of Pinguecula
Conservative Management is First-Line
For most pingueculae, treatment is conservative with artificial tears for minor irritation, as these benign lesions do not affect vision and often require no intervention. 1
When Inflammation Occurs (Pingueculitis)
Topical Anti-inflammatory Therapy
Topical corticosteroids are highly effective for acute pingueculitis, with prednisolone acetate 1% four times daily for 2 weeks demonstrating significant reduction in conjunctival thickness, cross-sectional area, and symptom scores that persist long-term. 2
Topical indomethacin 0.1% solution represents an alternative anti-inflammatory option, administered six times daily for 3 days, then four times daily for 11 days, showing significant improvement in both objective signs (conjunctival congestion, redness, edema) and subjective symptoms (photophobia, pain, foreign-body sensation) compared to placebo. 3
Preservative-free formulations should be considered when using topical corticosteroids for conjunctival inflammation to minimize additional irritation. 4
Clinical Monitoring
Anterior segment optical coherence tomography (AS-OCT) allows quantification of pinguecula dimensions before and after treatment, demonstrating conversion back to homogeneous conjunctival stroma after successful anti-inflammatory therapy. 2
Follow-up at 1 month post-treatment is appropriate to assess response, with sustained improvement typically maintained up to 1 year. 2
Surgical Intervention
Indications for Removal
Surgical removal should be considered only when conservative measures fail and symptoms significantly impact quality of life, as a conservative approach is advocated since surgical removal may result in recurrence that is more difficult to manage than the primary lesion. 1
For pinguecula-related dry eye disease refractory to medical treatment, argon laser photocoagulation has been reported as an effective alternative, achieving complete resolution of symptoms and normalization of tear film parameters (Schirmer test, fluorescein break-up time). 5
Surgical Technique Considerations
- When surgical excision is performed, complete removal is essential, as incomplete removal may lead to persistent symptoms or recurrence. 5
Associated Dry Eye Management
Aggressive lubrication with artificial tears should be the foundation of treatment for any associated dry eye symptoms, as pingueculae can disrupt tear film stability. 1, 2
Tear film break-up time and Schirmer testing help quantify the severity of associated dry eye and monitor treatment response. 5
Important Clinical Pearls
Pingueculae presenting with chronic unilateral symptoms, recurrent inflammation, or significant elevation (>700 μm on OCT) may warrant more aggressive management. 5
The association between pinguecula and underlying conditions such as Sjögren's syndrome should be considered in patients with bilateral lesions or severe dry eye symptoms. 6
Mild stinging for less than 1 minute after topical indomethacin administration is expected and should not prompt discontinuation. 3