What is the diagnosis and treatment for a patient with white thick bumps on the sclera, possibly related to pinguecula, considering their overall medical history, age, and history of UV exposure?

White Thick Bumps on Sclera

The most likely diagnosis is pinguecula, a benign yellowish-white elevated lesion on the bulbar conjunctiva adjacent to the limbus, typically caused by chronic UV exposure and requiring no treatment unless symptomatic. 1

Clinical Diagnosis

Pinguecula presents as:

• Yellowish or whitish elevated masses on the bulbar conjunctiva, most commonly on the nasal side near the limbus 1
• Benign lesions composed of degenerated basophilic subepithelial tissue that do not affect vision 1
• Associated with chronic UV light exposure, outdoor work environments, and aging 2, 3

Key diagnostic features on examination:

• Slit-lamp biomicroscopy should evaluate the location, depth, elevation, and associated findings of the lesion 4
• The lesion typically appears as a raised, yellowish-white bump on the conjunctiva adjacent to but not crossing the corneal limbus 1
• Optical coherence tomography can measure lesion height (typically 400-740 µm in symptomatic cases) 5

Critical Differential Diagnoses to Exclude

You must rule out malignancy in elderly patients or those with atypical features:

• Conjunctival melanoma: Painless, flat or nodular brown or white-pink lesions on bulbar or palpebral conjunctiva that can enlarge, develop blood vessels, or thicken 4
• Sebaceous carcinoma: Yellowish discoloration of the tarsal plate or subconjunctival multilobulated yellow mass, particularly in elderly patients with history of multiple excisions 4
• Ocular surface squamous neoplasia: Conjunctival hyperemia with papillomatous or sessile nodules, associated with HPV and significant UV exposure 6

Warning signs requiring biopsy: 4

• Enlargement of the lesion over time
• Development of new blood vessels within the lesion
• Thickening or nodularity
• Recurrence in the same location after previous excision
• Elderly patient with multiple prior excisions

Management Approach

For asymptomatic pinguecula:

• No treatment is necessary as these lesions do not affect vision 1
• Conservative observation is the standard approach 1

For symptomatic pinguecula (irritation, redness, discomfort):

• Artificial tears are first-line therapy for minor irritation 1
• If symptoms persist despite artificial tears and include chronic dry eye features (reduced tear break-up time <5 seconds, Schirmer test <5mm, persistent conjunctival injection), consider argon laser photocoagulation 5
• Surgical excision is generally not recommended for primary pinguecula, as removal may result in recurrent lesions that are more difficult to manage than the primary lesion 1

When to refer to ophthalmology:

• Atypical features suggesting malignancy (irregular borders, pigmentation changes, vascularization, rapid growth) 4
• Elderly patients with yellowish lesions and history of multiple excisions 4
• Lesions that cross onto the cornea (pterygium rather than pinguecula) that may affect the visual axis 1
• Severe symptoms refractory to conservative management 5

Prevention and Patient Counseling

UV protection is essential: 2, 3

• Recommend UV-blocking sunglasses and wide-brimmed hats for outdoor activities
• Pinguecula is strongly associated with chronic UV exposure and outdoor work environments 2
• Fuchs flecks identified by confocal microscopy may represent precursor lesions to UV-associated ocular surface pathology, including pinguecula and pterygium 3