PINGUECULA

Indra P SharmaOptometrist, Bhutan

Objective

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To have a better understanding about pinguecula with regard to its pathophysiology, clinical manifestation, management and prevention.

Contents

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1. Overview of pinguecula2. Pathophysiology3. Etiology4. Clinical features and differential diagnosis5. Treatment6. Possible complication7. Culprit in CL practice8. Prevention 9. Conclusion 10. References

Introduction

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Common degenerative condition of the conjunctiva.

Yellowish white patch on the bulbar conjunctiva.

Derived from pinguis (meaning fat ) Considered a precursor of pterygium

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Typical pinguecula

Characteristics

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Presents as yellowish white patch near limbus. Usually affects the nasal side first and then the

temporal side. When conjunctiva is congested, it stands out

as an avascular prominence. Calcification occurs occasionally. Remain stationary or may enlarge gradually

over long periods of time.

ICD Code International Classification of Disease (ICD)

code for Pinguecula

ICD-10 : H11.1

ICD-9 : 372.51

Sharma IP

Epidemiology

Male: female= 2:1 Most common over the age of 40 But may occur in 20 and 30 years old adults

who spend significant time in the sun. May have an increased prevalence

in Gaucher's disease.

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Pathology

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Elastotic degeneration o f collagen fibres of the substantia propria of conjunctiva

Plus deposition of amorphous hyaline material in the substance of conjunctiva.

Histologically it shows degeneration of the collagen fibers of the conjunctiva stroma with thinning of the overlying epithelium and occasional calcification

Etiology

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Etiology is not known exactly.

Contd..

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UV radiation is thought to be main trigger factor.

Therefore, the incidence is much higher in equatorial countries

Contd..

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Incidence is much higher in equatorial countries

More in those who are usually outdoor

Contd...

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Figure : The UV radiation affects the temporal area and travels through the cornea to the nasal area, where the UV power increases up to 20 times more.

Contd...

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Insults such as welding.

Dust and wind.

Clinical features

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Symptoms Usually asymptomatic Ocular irritation and discomfort Aesthetic concerns Recurrent inflammation

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Signs Appearance of yellow-white, amorphous

subepithelial deposits epithelium. Appear adjacent to the limbus in the

interpalpebral zone, more often nasally. Conjunctiva overlying a pinguecula may be

normal, thick, or thin.

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Differential diagnosis Squamous Cell Carcinoma Bitots spot Phlectenule

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Examination and diagnosis Obvious clinical diagnosis

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No treatment required

Treatment

Contd..

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Lubricant to alleviate ocular irritation

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Excision indicated when pinguecula Cause cosmetic problems become chronically inflamed(pingueculitis) interfere with successful contact lens wear.

Contd..

Contd... In a study (July 2013) removal of pingueculae

with a laser vs. traditional surgical excision was compared.

Researchers found Eyes treated with argon laser

photocoagulation- (90.5 %) complete removal of pingueculae

Eyes treated with traditional surgical excision - (63.9 %) complete removal

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Weak topical steroids Judicious use of weak topical steroids may be

considered in patients with chronic inflammation.

Eg. Gtt. Fluorometholone tds reducing over 3 weeks.

But they are strongly discouraged as a chronic therapy due to their side effects

Contd..

Complication

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Rare complication inflammation,

intraepithelial abscess formation

rarely conversion into pterygium

Prognosis Visual and cosmetic prognosis is good. Vision is not affected. No systemic and genetic association noted.

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The culprit in CL practise A common scleral obstrucle in CL practise. Small pinguecula doesnt cause problem. However larger can cause decentration of

contact lens.

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Contd

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The firm nature of scleral GPs can cause patients significant irritation if the lens edge bumps into the pinguecula, or their rigidness will prevent an acceptable fit if an elevated pinguecula lies beneath the haptic.

In such cases, we consider a corneal GP, soft specialty design, or hybrid design. Alternatively, a notch can be beveled out of a scleral lens, which will allow it to bypass the pinguecula.

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Aviod eye irritants

Prevention

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Good quality Sunglasses

Hats and caps

Contd...

Conclusion

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Pingucula is a common disease. Lubrication is the mainstray treatment. Most cases can be managed by optometrist. Some special attention may be required in

contact lens practise.

Reference

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Books and journals American Academy of Ophthalmology, External Disease and Cornea

,Section 8 (2011-2012), 12: 331-332 Kamel S. The pterygium: its etiology and treatment. Am J Ophthalmology,

1954;152(5):733-8 Kanski Jack J, Clinical Ophthalmology- A systemic approach, 6th Ed,

Butterworth Heineman Elsevier. 8: 242 Jackson Timothy L, Moorfield Mannual of Ophthalmology, Mosby Elsevier,

4:137

Websites: http://pterigion.net/2012/09/03/pterygium-what-is-it-how-is-it-treated/

retrieved on 1/2/2015 http://www.nytimes.com/health/guides/disease/pinguecula/overview.html

retrieved on 1/2/2015 http://www.clspectrum.com/articleviewer.aspx?articleID=107286 retrieved

on 1/2/2105 http://en.wikipedia.org/wiki/Pinguecula retrieved on 1/2/2105

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Questions? What are the causes of pinguecula? Why is the prevelance of pinguecula more in

male? What is the optometric management of

pinguecula? What are the indication for pinguecula

excision?

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Tashi Delek

Sharma IP