What is the recommended management for an asymptomatic pingueculum on the bulbar conjunctiva?

Management of Asymptomatic Pinguecula

For an asymptomatic pinguecula on the bulbar conjunctiva, no treatment is required—observation alone is appropriate. 1

What is a Pinguecula?

A pinguecula is a benign, raised conjunctival nodule composed of degenerated basophilic subepithelial tissue, typically located at the nasal or temporal limbus of the bulbar conjunctiva. 1 These lesions are classically associated with chronic conjunctival microtrauma from ultraviolet light exposure and environmental irritants such as dust. 2, 1

Management Algorithm for Pinguecula

Asymptomatic Pinguecula

• No intervention is needed—these lesions do not affect vision and require only observation. 1
• Patient reassurance about the benign nature of the condition is appropriate. 1

Symptomatic (Inflamed) Pinguecula

• Mild irritation: Manage with artificial tears for lubrication and symptomatic relief. 1
• Acute inflammation (redness, edema, discomfort): Topical indomethacin 0.1% solution is effective, dosed six times daily for 3 days, then four times daily for 11 additional days. 3
  • This regimen significantly reduces conjunctival congestion, redness, edema, photophobia, foreign-body sensation, and tearing within 3 days, with continued improvement through 14 days. 3
  • Patients should expect mild stinging lasting less than 1 minute after drop instillation. 3

When to Consider Surgical Excision

• Surgery is not indicated for asymptomatic pingueculae, as they do not threaten vision. 1
• Excision may be considered only for:
  • Persistent severe inflammation unresponsive to medical therapy
  • Cosmetic concerns (patient-driven decision)
  • Rare progression to pterygium (fibrovascular growth crossing the limbus onto the cornea)

Critical Differential Diagnoses to Exclude

While pinguecula is typically straightforward, certain red-flag features warrant biopsy or urgent ophthalmology referral:

• Sebaceous carcinoma: Unilateral intense conjunctival injection with scarring, hard non-mobile tarsal mass with yellowish discoloration, or history of recurrent "chalazion" excisions. 4
• Ocular surface squamous neoplasia: Conjunctival hyperemia with papillomatous or sessile nodules, especially with history of HPV infection or significant UV exposure. 4
• Conjunctival melanoma: Painless flat or nodular brown/white-pink lesion with enlargement, prominent blood vessels, or thickening. 5
• Atypical fibroxanthoma: Rapidly growing vascularized conjunctival mass with raised nodular edge (extremely rare). 6

Key Clinical Pitfalls to Avoid

• Do not confuse pinguecula with pterygium: Pterygium is a fibrovascular growth that crosses the limbus and extends onto the cornea, potentially affecting vision and requiring surgical intervention. 7, 1 Pinguecula remains confined to the bulbar conjunctiva and does not cross the limbus. 1
• Do not initiate treatment for asymptomatic lesions: Unnecessary intervention increases risk without benefit. 1
• Consider systemic associations in atypical presentations: Pinguecula has been rarely reported in association with Sjögren's syndrome, though this is uncommon. 2

Follow-Up Recommendations

• Asymptomatic pinguecula: No routine follow-up required; advise patient to return if symptoms develop (redness, irritation, vision changes). 1
• Symptomatic pinguecula on treatment: Re-evaluate at 3,7, and 14 days to assess response to topical anti-inflammatory therapy. 3