CE Credit Article

Clinical & Refractive Optometry is pleased to present this continuing education (CE)
article by Dr. Mark Eltis entitled Pingueculae and Their Clinical Implications. In order to
obtain a 1-hour Council of Optometric Practitioner Education (COPE) approved CE credit,
please click on the Take Test button on the Home Page and follow the on-screen instructions.

Pingueculae and Their Clinical Implications

Mark Eltis, OD

ABSTRACT
A pinguecula is a raised white to yellowish lesion on
the conjunctiva which does not cross onto the cornea.
It is an alteration of the existing tissue and generally
develops after the age of forty. While the exact cause is
unknown, UV exposure and other factors seem to be
implicated. Treatment with artificial tears or antiinflammatory drops is required if the patient is
symptomatic. In addition, education on UV protection
and avoidance of irritating factors are important.

INTRODUCTION
Pingueculae are among the more common conjunctival
disorders with prevalence rates ranging from 22.5% to
90%.1-4 Pingueculae are benign, white to yellow raised
lesions which can sometimes have a lipid-like appearance.1,5 Pingueculae are typically located at the three and
nine oclock positions on the bulbar conjunctiva near the
sclerocorneal junction but do not cross into the cornea.4,6,7
Although the root cause is not fully understood, UV
exposure is thought to be implicated in the etiogenesis.1,5,7-9
Pingueculae are thought to result from exposure to UV
radiation, which changes the structure of the collagen and
elastic tissues of the stroma.5,10
Not surprisingly, prevalence rates for pingueculae
seem to be higher in tropical countries.3 Other factors
which may be associated with pingueculae are: age, wind,
smoke, dust and possibly contact lens wear.4,8,10,11 The
condition generally develops after the age of forty.4
Common symptoms include foreign body sensation and
contact lens intolerance.12 Inflammation and redness as
well as associated dry eye may also be present.13

M. Eltis Private Practice, Toronto, Ontario

Correspondence to: Dr. Mark Eltis, Hudson Bay Centre - Concourse
Level, 44 Bloor Street East, Toronto, Ontario M4W 3H7;
E-mail: Mark.eltis@gmail.com

10

Clinical & Refractive Optometry 22:1/2, 2011

CASE REPORT
A 45-year-old woman who recently immigrated to
Canada from the Philippines presented to our office on
April 1, 2010 for a routine exam. She reported that a mild
foreign body sensation in the nasal side of her left eye
had started the previous night. She was not taking any
medication and had no history of eye or general health
problems. The patient had neither worn contacts nor had
any corrective surgery. The patient had no known allergies
and was not aware of health conditions in her family. She
was neither a smoker nor drinker and did not engage in
recreational drug use. The patient worked as a personal
support worker (PSW) and rarely used a computer.
Presenting distance visual acuities through her Rx
(-2.00 D OD and -2.00 D OS) were 6/6 (20/20) OD,
OS and OU. She preferred to remove her glasses to
read rather than wear bifocal or reading glasses. Her
uncorrected visual acuity at near (forty centimetres
working distance) was also 6/6 (20/20) OD, OS and OU.
Extraocular muscles were unrestricted in all gazes.
Pupils were round and reactive to light and accommodation
with negative Marcus Gunn. Confrontation visual fields
were full to finger count in both eyes, and near point of
convergence was six centimetres. Cover test was ortho in
the distance and two PD exophoric at near. Her distance
refraction remained unchanged and her near add was
+1.25 D OU.
Slit lamp examination revealed normal lids and lashes.
There were yellowish raised masses on the nasal and
temporal conjunctivas of both eyes at the three and nine
oclock positions. The mass on the nasal side of the left
eye was more prominent and slightly swollen. There was
no vascularization of the growths and they did not cross
the limbus. Both corneas were clear and did not stain with
fluorescein. Both crystalline lenses were clear and so
were the media of both eyes. Anterior chambers were
without cells or flare and were estimated by VonHerrick
grading to be 4/4. Intraocular pressure was 15 mmHg in
both eyes at 5:30 p.m. using Perkins applanation tonometry.
A super field lens and a binocular indirect ophthalmoscope were used to examine the fundus. Cup-to-disc ratios
were 0.2/0.2 and symmetrical in both eyes. The optic
nerves were normal in both eyes and the neuroretinal rims
were healthy and intact. The arterial/venous ratio was

2/3 OU and the retinal vessels appeared normal. Maculas

were clear in both eyes and a foveal reflex was still
present. There were neither holes, tears nor retinal
detachment in either eye.
The following differential diagnoses were considered
in this case: 1. Pinguecula; 2. Pterygium; 3. Conjunctival
intraepithelial neoplasia; 4. Retention cyst; and 5.
Squamous cell carcinoma.
1. Pinguecula is a yellowish white mass which is often
bilateral and not vascularized.5 It is typically found at the
three and nine oclock positions in the bulbar conjunctiva.7
It does not involve the cornea.14
2. Pterygium is a wing-like fibrovascular growth or fold
caused by UV radiation and chronic dryness.7,15 It starts in
the interpalpebral conjunctiva and crosses onto the
cornea.14 Pterygia are typically nasal in location.10,14
3. Conjunctival intraepithelial neoplasia is a unilateral
jelly-like mass which is vascularized and not in the
typical three or nine oclock position of a pinguecula or
pterygium.14 It usually begins at the limbus.12 It is generally
pink and nodular and is a precursor to squamous cell
carcinoma.12
4. A retention cyst contains clear fluid and has a thin wall.7
It can be classified by its lining as either ductal or
inclusion. It is due to trauma or inflammation but may be
congenital.12
5. Squamous cell carcinoma has a gelatinous papillary
appearance with loops of blood vessels.5,12 It is rarely
metastatic or likely to be associated with deep invasion of
the cornea.5,12 It may be associated with AIDS in patients
under fifty.12
The growth on the patients eyes did not cross the
limbus (as does a pterygium) and did not have a wing-like
(or wedge-shaped) structure. They were neither nodular,
gelatinous, vascularized nor pink, and that typically rules
out conjunctival intraepithelial neoplasia and squamous
cell carcinoma. Unlike cysts, the lesions were not clear
and fluid-filled. Therefore, the patient was diagnosed with
an inflamed pinguecula (pingueculitis). The nasal irritated
pinguecula on the left eye was consistent with the area of
the foreign body complaint.
The patient was educated on the presence of pingueculae in both her eyes. She said she occasionally noticed
her eyes would get irritated in those areas and was
relieved to learn why. The patient was educated on the
need to wear sunglasses and a wide-brimmed hat when
outdoors as UV exposure was the likely cause of her
pingueculae. Use of artificial tears GenTeal Gel Drops,

Novartis Ophthalmics (one drop four times per day in the

affected eye) was suggested. The patient was told that the
condition should improve within the next few days, but
that due to its chronic nature it may reoccur. The patient
was advised to return if her condition did not improve or
worsened over the course of the next few days.
Follow-Up #1
The patient returned for a follow-up one week later. She
no longer had any symptoms. Her presenting VA at
distance was 6/6 (20/20) OD and OS through spectacle
correction. Slit lamp exam demonstrated a reduction in
inflammation of the pinguecula on the nasal quadrant of
the left eye. Otherwise the exam was unremarkable. The
patient was invited to use artificial tears GenTeal Gel
Drops as needed and wear UV protection and a widebrimmed hat when outdoors.

DISCUSSION
While pingueculae are extremely common, studies
regarding them are rare.3 An eye study from Tehran found a
prevalence of 22.5% with a significant increase with age.3
While UV radiation is generally accepted as the main cause
of pingueculae formation, this relationship is based on a
relatively limited number of epidemiological studies.5
A common myth among eye care practitioners is that
pingueculae evolve into pterygia, but they are in fact
separate entitites.5 Contact lens wearers may suffer tear film
instability, which could be a factor in the pathogenesis of
pingueculae.4 Although the pathogenesis of pingueculae
remains unclear, it has recently been suggested that UVradiation-induced racemisation of aspartic acid is
implicated, resulting in abnormal deposits of elastic fibres in
the substantia propria.8,16 This would mean a pinguecula is
an elastic degeneration of the substantia propria where
normal collagen is replaced with thicker fibres.10,13 Most
recently, a study concluded for the first time that the
abnormal cell differentiation of pinguecula is characterized
by squamous metaplasia with proliferation.1
Histologically, the most telling feature is the
sub-epithelial senile elastosis.2,5,6,17 Elastic fibres are
abnormal in biochemical composition possibly due to P53
mutations in limbal epithelial cells.17 Other findings
include conjunctival epithelial changes, which can range
from atrophy, hyperplasia, metaplasia or dysplasia.2
Pingueculae may be located in either the nasal or the
temporal bulbar conjunctiva but do not involve the
cornea.2,13 The condition has a predilection for the nasal
side of the conjunctiva.10,13 It is believed that this is caused
by light reflecting off the nose onto the nasal conjunctiva.5
Pingueculae are often bilateral not vascularized and
may calcify over time.5,12
When a pinguecula is inflamed, the dilated blood
vessels permit histamine, serotonin, bradykinin and

Pingueculae and Their Clinical Implications Eltis

11

prostaglandins to be released and to result in the

symptoms of pingueculitis.16
One grading system for pingueculae is as follows:
P (0) = none P (1) = mild or moderate P (2) = severe.4
When Utine et al investigated the autofluorecsence
(AF) properties of pingueculae, they found that pingueculae
display hyperautofluorescence in AF imaging.2 This
indicates that the actual size of a pinguecula is larger than
its visible size and can be estimated using this technique.2
The results of the first study to investigate the
relationship between pingueculae and contact lens wear
were published earlier this year.4 The research showed
that both the grade and prevalence of pingueculae were
higher in contact lens wearers in general and hard contact
lens wearers in particular.4 It is possible that soft contact
lenses provide limbal UV protection and cause less
friction than HCL.4 Continual friction and inflammation
of the conjunctiva due to the edge of the contact lens as
well as dryness may cause pingueculae formation in
younger people.4
Studies have demonstrated normal tear secretion but
decreased TFBUT with pingueculae.1 TFBUT was also
substantially increased after a single excision.1 This
highlights the potentially significant impact of pingueculae
on tear film stability and its underestimated role in dry
eye.1 However, the relationship between pingueculae and
tear film disruption has not produced uniform results.
Another study (in Nigeria) found no relationship between
tear film disruption and formation of pingueculae.11
There may be a slightly increased risk of cortical
cataract formation in patients with pingueculae, although
that association is still controversial.18 While UV
protection has been shown to decrease the risk of AMD,
no relationship has been found between pingueculae and
incidence of AMD.9
Clearly, protecting the eyes from UV radiation, wind
and dust should be suggested to all patients, particularly
those patients with pingueculae.14,15,19 Although treatment for
pingueculae is rarely required, artificial tears (such as
GenTeal Gel Drops) may be used in mild cases of
irritation: one drop, four times per day in the affected eye.13,14
If inflammation is more severe, a brief course of
topical steroids may be indicated.10 One percent
prednisolone acetate suspension or 0.5% loteprednol
etabonate suspension may be used qid.10,13,14,16
Surgery is considered a last resort either in cases of
chronic persistent irritation, when the aforementioned
treatment has failed, when interference with contact lens
wear occurs or for cosmetic purposes.3,5,13,14 Excision
followed by histological evaluation can be used to exclude
more serious pathology when the pinguecula is atypical in
either location or appearance.6,17
A large amount of evidence suggests that UV radiation
can have negative consequences for the eyes.15,21

12

Clinical & Refractive Optometry 22:1/2, 2011

While wearing UV protection has been widely

emphasized by health care professionals for some time, it
cannot be overstated.5,15,19-22 The eye is protected by
the nose, eyelids and cheeks, which act as barriers against
UV radiation.5,15 Wraparound sunglasses, wide-brimmed
hats and avoidance of sun exposure during mid-day
hours are particularly effective strategies for minimizing
sun damage.15,18,20-22
A wide-brimmed hat or visor can reduce the amount of
light reaching the eye by up to 30%.5,18 Polycarbonate and
high index lenses block all UVA and UVB up to 380 nm.5
CR39 blocks UVB while crown glass does not have any
UV-blocking properties.5 Transitions lenses offer 100% UV
protection.5 Polarized lenses offer additional protection and
some contact lenses offer UV protection as well.5,19
Young people are more vulnerable to the harmful
effects of UV radiation than the general population.20,22 In
a recent study, 57% of students believed that sunscreen
applied to the face offered fair to good protection for the
eyes.20 While the majority of students in the study owned
sunglasses almost half (44.5%) never wore them.20 As in
other studies, the reported frequency of wearing sunglasses
was related to peer influences as well as media messages.20-22
Therefore, health promotion and education are
imperative at an early age; the habits formed in this
critical period will carry on later in life.15-22

CONCLUSION
Pingueculae are extremely common and can occasionally be
symptomatic. The contribution of pingueculae to ocular
discomfort, dry eye symptoms and potential contact lens
intolerance may be underestimated. Patient education and
prevention including UV protection are critical.

REFERENCES
1.

2.
3.
4.

5.

6.

Dong N, Li W, Lin H, Wu H, Li C, Chen W, Qin W, Quyang

L, Wang H, Liu Z. Abnormal epithelial differentiation and
tear film alteration in pinguecula. Invest Ophthalmol Vis
Sci 2009; 50(6): 2710-2715.
Utine CA, Tatlipinar S, Altunsoy M, Oral D, Basar D,
Alimgil LM. Autofluorescence imaging of pingueculae.
Br J Ophthalmol 2009; 93(3): 396-399.
Fotouhi A, Hashemi H, Khabazkhoob M, Mohammad K.
Prevalence and risk factors of pterygium and pinguecula:
the Tehran eye study. Eye (Lond) 2009; 23(5): 1125-1129.
Mimura T, Usui T, Mori M, et al. Pinguecula and contact
lenses. Eye (Lond) 2010; [Epub ahead of print] Available at
http://www.nature.com/eye/journal/vaop/ncurrent/full/eye2
010120a.html
Taub MB. Ocular effects of ultraviolet radiation.
Optometry Today 2004; 44(12): 34-38. Available at
http://www.optometry.co.uk/articles/docs/862d3760089d6
4ef0197535e41f02fa6_taub20040618.pdf
Dhermies F, Meyer A, Sam H, Morel X, Halhal M,
Elmaleh C, Fayet B, Behar-Cohen F, Bitan P, Renard G.
[Inflammation of an ectopic pinguecula]. J Fr Ophtalmol
2002; 25(9): 979-982.

7.
8
9.
10.
11.
12.
13.
14.
15.

Kanski, JJ. Clinical ophthalmology: a synopsis. 2nd Ed.

Oxford: Butterworth-Heinemann Ltd., 2009: 134-136.
Kaji Y, Oshika T, Okamoto F, Fujii N. Immunohistochemical localisation of D-beta-aspartic acid in
pingueculae. Br J Ophthalmol 2009; 93(7): 974-976.
Pham TQ, Wang JJ, Rochtchina E, Mitchell P. Pterygium/
pinguecula and the five-year incidence of age-related
maculopathy. Am J Ophthalmol 2005; 139(3): 536-537.
Blereau RP. Pinguecula. Consultant 2005; 45(1): 73.
Balogun MM, Ashaye AO, Ajayi BG, Osuntokun OO. Tear
break-up time in eyes with pterygia and pingueculae in
Ibadan. West Afr J Med 2005; 24(2): 162-166.
Kaiser P, Friedman N, Pineda R.The Massachusetts eye and
ear infirmary illustrated manual of ophthalmology. 2nd Ed.
Philadelphia: Saunders, 2003: 131-137.
Bell A. Pinguecula. J Vis Commun Med 2006; 29(2): 82-83.
Ehlers JP, Shah CP. The Wills eye manual: office and emergency room diagnosis and treatment of eye disease. 5th Ed.
Baltimore: Lippincott Williams & Wilkins, 2008: 59-60.
Wang SQ, Balagula Y, Osterwalder U. Photoprotection: a
review of the current and future technologies. Dermatol
Ther 2010; 23(1): 31-47.

16. Anonymous. Pingueculitis. Rev Optom 2006; 143(3):

16(A).
17. Suresh K, Doctor P. Pinguecula masquerading as conjunctival melanoma. Indian J Ophthalmol 2007; 55(1): 83-84.
18. Pham TQ, Wang JJ, Rochtchina E, Mitchell P. Pterygium,
pinguecula, and 5-year incidence of cataract. Am J
Ophthalmol 2005; 139(6): 1126-1128.
19. Chandler HL, Reuter KS, Sinnott LT, Nichols JJ.
Prevention of UV-induced damage to the anterior segment
using class I UV-absorbing hydrogel contact lenses. Invest
Ophthalmol Vis Sci 2010; 51(1): 172-178.
20. Pakrou N, Casson R, Fung S, Ferdowsi N, Lee G, Selva D.
South Australian adolescent ophthalmic sun protective
behaviours. Eye (Lond) 2008; 22(6): 808-814.
21. Paul C, Tzelepis F, Parfitt N, Girgis A. How to improve
adolescents sun protection behavior? Age and gender
issues. Am J Health Behav 2008; 32(4): 387-398.
22. Livingston PM, White V, Hayman J, Dobbinson S.
Australian adolescents sun protection behavior: who are
we kidding? Prev Med 2007; 44(6): 508-512.

Pingueculae and Their Clinical Implications Eltis

13