What is a pinguecula and what are the recommended management options?

Pinguecula: Definition and Management

A pinguecula is a benign, yellowish conjunctival lesion composed of degenerated subepithelial tissue that does not affect vision and is primarily managed conservatively with artificial tears for minor irritation. 1

What is a Pinguecula?

• Pinguecula is a benign peribulbar lesion consisting of degenerated basophilic subepithelial tissue that appears as a small, raised conjunctival nodule typically located at the temporal or nasal limbus 1
• The lesion presents as a yellowish, elevated area of conjunctiva that protrudes from the ocular surface 2
• Pingueculae do not affect the visual axis or impair vision, distinguishing them from pterygia which can encroach onto the cornea 1
• The condition is age-dependent and increases dramatically with age, occurring from young adulthood onward 3
• Male patients tend to have higher-grade pingueculae than female patients on both nasal and temporal conjunctiva 3

Primary Risk Factors

• Chronic conjunctival microtrauma from sunlight exposure is the classic association 4
• Dust and environmental exposure contribute to development 4
• Sjögren's syndrome has been reported in association with pinguecula, though this is rare 4

Conservative Management (First-Line)

Most pingueculae require only conservative management, as they are benign and do not threaten vision. 1

• Artificial tears (preservative-free formulations preferred) are the mainstay of treatment for minor irritation and associated dry eye symptoms 1, 5
• Observation alone is appropriate for asymptomatic lesions that are not cosmetically concerning to the patient 1
• When topical corticosteroids are needed for conjunctival inflammation, preservative-free formulations should be used to minimize additional irritation 5

Surgical Management (Reserved for Specific Indications)

Surgery should be reserved for pingueculae causing significant symptoms or cosmetic concerns, as the lesion itself is benign. 1

Indications for Surgical Excision:

• Persistent dry eye symptoms refractory to conservative management 2
• Cosmetic concerns when the lesion is prominent and bothersome to the patient 6
• Significant conjunctival protrusion (at least 2 times thicker than adjacent normal conjunctiva on anterior segment OCT) 2

Surgical Technique:

• Pinguecula excision with conjunctival autograft secured with fibrin glue is the preferred surgical approach 2, 6
• This technique has demonstrated improvement in tear film breakup time, Schirmer test scores, and dry eye symptom scores at 3 months postoperatively 2
• Vascular regression occurs following excision with conjunctival autografting, improving cosmetic outcomes 6
• Cosmetic results are excellent or good in 93.5% of cases using this technique 6

Critical Management Pitfalls

• Do not pursue aggressive surgical management for asymptomatic pingueculae, as the lesion is benign and surgery carries unnecessary risks 1
• Distinguish pinguecula from pterygium, as pterygia may affect the visual axis and require different management considerations 1
• Ensure proper patient selection for surgery, limiting procedures to those with documented symptoms or significant cosmetic concerns rather than operating on incidental findings 2, 6

Monitoring and Follow-Up

• Routine follow-up is not necessary for stable, asymptomatic pingueculae managed conservatively 1
• For patients undergoing surgical excision, 12-month follow-up demonstrates sustained vascular regression and cosmetic improvement 6
• Anterior segment photography can be used to document baseline appearance and track changes over time if surgery is being considered 6