Pinguecula and Pterygium

Question 1

Parts of the conjuctiva?

Answer 1

1. bulbar conjunctiva
2. palpebral conjunctiva
3. conjunctival fornix

Question 2

What is a pinguecula?

Answer 2

• 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

Question 3

Epidemiology of pinguecula?

Answer 3

• 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

Question 4

Pathophysiology of pinguecula?

Answer 4

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).

Question 5

Grading of pinguecula?

Answer 5

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

Question 6

Risk factors for developing a pinguecula?

Answer 6

1. age > 40 years’
2. Exposure to sunlight, dust and sand
3. Occupational hazard
   e.g. farmers, surfers
4. Living in high altitudes
   - thin atmosphere ,more UV light
5. Contact lens wear
   - may cause friction and inflammation

Question 7

Signs of pinguecula?

Answer 7

• 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

Question 8

Symptoms of local irritation of a pinguecula?

Answer 8

1. redness
2. lacrimation
3. foreign body sensation

Question 9

Ddx for pinguecula?

Answer 9

1. Pterygium
2. Conjunctival lymphoma
3. Limbal dermoid
   - congenital condition presenting as mass at limbus containing hair follicles and sebaceous gland
4. Conjunctival cyst
5. Conjunctival foreign body

Question 10

Diagnosis of pinguecula?

Answer 10

• Clinical diagnosis
• Typically diagnosed through a standard eye exam ,using a slit-lamp to closely examine the surface of the eye

Question 11

Management of pinguecula?

Answer 11

1. Safeguard eyes from ultraviolet light, wind, and dust (photochromic sunglasses and dust protecting hats)
2. Use of artificial tears when eyes are dry
3. Surgical excision may be necessary in severe inflammation or for cosmetic reasons

Question 12

Prognosis for penguecula?

Answer 12

Good (usually only causes cosmetic problems)

Question 13

Complications of pinguecula?

Answer 13

1. Pterygium formation
2. May arise after excision
   - Recurrence of pinguecula
   - Pigmentary changes at site of removal

Question 14

What is pterygium?

Answer 14

• 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

Question 15

Epidemiology of pterygium?

Answer 15

1. Increased incidence in regions near the equator (between 30 degrees north and 30 degrees south also known as pterygium belt)
2. Increased incidence among older males with outdoor occupations due to chronic sun exposure

Question 16

Pathophysiology of pterygium?

Answer 16

• 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.

Question 17

Classification of pterygium?

Answer 17

1. according to progression
2. grading system

Question 18

Classifying pterygium according to progression?

Answer 18

1. Progressive
   - thick, fleshy, vascular, progressively encroaching towards the center of the cornea
2. Atrophic/regressive
   - Thin, attenuated, poor vascularity, stationary

Question 19

Classification of pterygium according to grading?

Answer 19

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

Question 20

Risk factors of pterygium?

Answer 20

1. Sex
   - Males twice as frequently as in females.
2. Age
   - Patients aged 20-40 years have the highest incidence.
3. Living in subtropical region
   - Chronic environmental irritation (UV rays, hot and dry weather, wind, dusty)
4. Family history

Question 21

Signs and symptoms of pterygium?

Answer 21

1. Triangular, fibrovascular wedge ofconjunctival tissue
   - Typically grows laterally starting from the nasal conjunctiva
   - Can extend to the cornea, leading to visual impairment
2. Symptoms of local irritation
   - scleral/corneal redness
   - lacrimation
   - foreign body sensation

Question 22

Ddx for pterygium?

Answer 22

1. Pinguecula
2. Ocular surface squamous neoplasia
3. Pseudo pterygium
   - conjunctival adhesion to cornea caused by limbal inflammation
4. Conjunctival intraepithelial neoplasia

Question 23

Diagnosis of pterygium?

Answer 23

1. Diagnosis is mostly clinical
2. Slit lamp examination.
3. OCT and biopsy rarely done to rule out dysplasia

Question 24

Conservative management of pterygium?

Answer 24

1. UV protection (e.g., sunglasses, hats)
2. Topical lubricants (e.g., artificial tears)
3. Topical NSAIDS or steroids should be considered in inflamed pterygium.

Question 25

Indications for excision and patch graft surgery in pterygium?

Answer 25

1. Visual impairment (e.g., due to irregular astigmatism or visual axis involvement) 2. Restrictive ocular motility 3. Disease progression 4. Chronic inflammation 5. If its more than 3mm

Question 26

Prognosis of pterygium?

Answer 26

Prognosis is good, however recurrence after surgical removal indicates a high risk of recurrence after subsequent procedures

Question 27

Complications of pterygium?

Answer 27

1. Reduced ocular motility 2. Induced astigmatism 3. Chronic scarring of the conjunctiva and the cornea 4. Recurrence  after surgical removal