Pinguecula and Pterygium Flashcards
Parts of the conjuctiva?
- bulbar conjunctiva
- palpebral conjunctiva
- conjunctival fornix
What is a pinguecula?
- A pinguecula is a raised yellowish plaque on the conjunctiva composed of protein, fat or calcium.
- It is one of the benign non-infectious conditions of the conjunctiva
- It does not tend to grow onto the cornea
Epidemiology of pinguecula?
- No sex or racial predilection
- the adults of age 40+
- Higher prevalence rates in areas with high sun exposure
- Almost all individuals show some evidence of pinguecula in their 80s.
- In Malawi, 3rd most common ocular diagnosis made among geriatric patients
Pathophysiology of pinguecula?
The submucosal elevations on the conjunctiva are as a result of exposure to UV light
- UV light triggers inflammatory response causing accumulation of collagen and elastin fibers leading to thickening of tissue
- Overtime tissue changes color (appearing yellowish ) and becomes more fibrous
- Therefore, located in the sun-exposed regions of the conjunctiva (interpalpebral fissure).
Grading of pinguecula?
P0 - No pinguecula
P1 - Mild or moderate pinguecula, yellowish white, and flat or slightly elevated lesions with a maximum diameter <5mm
P3 - Severe pinguecula, highly vascularized and elevated lesion or large pinguecula with a diameter >5mm
Risk factors for developing a pinguecula?
- age > 40 years’
- Exposure to sunlight, dust and sand
- Occupational hazard
e.g. farmers, surfers - Living in high altitudes
- thin atmosphere ,more UV light - Contact lens wear
- may cause friction and inflammation
Signs of pinguecula?
- Yellowish raised plaque on the conjunctiva
- Most commonly located on the nasal but can also develop on the lateral conjunctiva
- Does not develop on the cornea
Symptoms of local irritation of a pinguecula?
- redness
- lacrimation
- foreign body sensation
Ddx for pinguecula?
- Pterygium
- Conjunctival lymphoma
- Limbal dermoid
- congenital condition presenting as mass at limbus containing hair follicles and sebaceous gland - Conjunctival cyst
- Conjunctival foreign body
Diagnosis of pinguecula?
- Clinical diagnosis
- Typically diagnosed through a standard eye exam ,using a slit-lamp to closely examine the surface of the eye
Management of pinguecula?
- Safeguard eyes from ultraviolet light, wind, and dust (photochromic sunglasses and dust protecting hats)
- Use of artificial tears when eyes are dry
- Surgical excision may be necessary in severe inflammation or for cosmetic reasons
Prognosis for penguecula?
Good (usually only causes cosmetic problems)
Complications of pinguecula?
- Pterygium formation
- May arise after excision
- Recurrence of pinguecula
- Pigmentary changes at site of removal
What is pterygium?
- Pterygium is a benign, fleshy (has blood vessels), triangular growth of conjunctival tissue which may spread across and distort the cornea
- Typically grows laterally starting from the nasal conjunctiva
- Pterygium refers to the shape of the tissue, which looks like an insect wing
Epidemiology of pterygium?
- Increased incidence in regions near the equator (between 30 degrees north and 30 degrees south also known as pterygium belt)
- Increased incidence among older males with outdoor occupations due to chronic sun exposure
Pathophysiology of pterygium?
- UV causes activation of the tissue growth factors, which further lead to angiogenesis and cell proliferation.
- The limbal stem cells are damaged by the UV rays that cause conjunctivalization (when cornea is covered by conjunctival epithelium) of the cornea, and the cornea is invaded by aggressive fibroblasts.
- UV radiation may cause mutations in the p53 tumor suppressor gene, resulting in the abnormal pterygial epithelium.
Classification of pterygium?
- according to progression
- grading system
Classifying pterygium according to progression?
- Progressive
- thick, fleshy, vascular, progressively encroaching towards the center of the cornea - Atrophic/regressive
- Thin, attenuated, poor vascularity, stationary
Classification of pterygium according to grading?
0 - no pterygium tissue
1 - pterygium tissue translucent, episceral vessels under the body of the pterygium are easily visible, minimally dilated vessels
3 - tissue is pink, vessels are distinguishable, dilated vessels with increased density
4 - tissue is red, vessels are not distinguishable, tortuous and engorged vessels
5 - tissue is deep bright diffuse red, very thick vessels are totally obscured, dense network of engorged vessels
Risk factors of pterygium?
- Sex
- Males twice as frequently as in females. - Age
- Patients aged 20-40 years have the highest incidence. - Living in subtropical region
- Chronic environmental irritation (UV rays, hot and dry weather, wind, dusty) - Family history
Signs and symptoms of pterygium?
- Triangular, fibrovascular wedge ofconjunctival tissue
- Typically grows laterally starting from the nasal conjunctiva
- Can extend to the cornea, leading to visual impairment - Symptoms of local irritation
- scleral/corneal redness
- lacrimation
- foreign body sensation
Ddx for pterygium?
- Pinguecula
- Ocular surface squamous neoplasia
- Pseudo pterygium
- conjunctival adhesion to cornea caused by limbal inflammation - Conjunctival intraepithelial neoplasia
Diagnosis of pterygium?
- Diagnosis is mostly clinical
- Slit lamp examination.
- OCT and biopsy rarely done to rule out dysplasia
Conservative management of pterygium?
- UV protection (e.g., sunglasses, hats)
- Topical lubricants (e.g., artificial tears)
- Topical NSAIDS or steroids should be considered in inflamed pterygium.
