Photo Quiz

Acute Red Eye



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Am Fam Physician. 2007 Sep 15;76(6):857-858.

A 28-year-old woman presented with a five-day history of redness (see accompanying figure) and mild pain in her left eye. She had not experienced discharge, blurry vision, or photophobia. The patient denied any history of trauma to the eye or participation in an occupation or hobby that put her at risk of a foreign body injury. She did not wear contact lenses. On examination, her uncorrected vision was 20/20 in both eyes.

Question

Based on the patient's history and physical examination, which one of the following is the most likely diagnosis?

A. Perilimbal nevus.

B. Pingueculitis.

C. Pterygium.

D. Subconjunctival foreign body.

E. Viral conjunctivitis.

Discussion

The answer is B: pingueculitis. A pinguecula is a common eye lesion. The lesion is a small, yellowish-white, elevated mass on the bulbar conjunctiva located on either side of the cornea, typically at the 3 and 9 o'clock positions (see accompanying figure). Sometimes the lesion becomes inflamed (pingueculitis).

Often, bilateral pingueculae represent degenerative conjunctival lesions. Histologically, the lesions contain deposits of degenerating collagen fibers, elastoid fibers, and an increased population of metabolically active stromal fibrocytes. Pingueculae are more common on the nasal side than the temporal side. The lesions may gradually enlarge over time but do not grow onto the cornea. The prevalence increases with age, and pingueculae occur in almost all persons older than 80 years.1

Pingueculae are likely actinic in origin, caused by damage from exposure to ultraviolet (UV) rays.2 For example, the histologic changes described above also occur in the dermis of sun-exposed skin. Given these findings, it seems prudent to protect the eyes from unnecessary exposure to UV radiation (e.g., avoiding sunlight between 10 a.m. and 2 p.m., when ambient UV radiation peaks). Patients should be counseled to use glasses and sunglasses that protect against UV radiation and to wear a brimmed hat.

The treatment of pingueculitis involves the use of artificial tears and/or mild topical steroids; topical nonsteroidal anti-inflammatory ophthalmic solutions (e.g., ketorolac [Acular], diclofenac [Voltaren], flurbiprofen [Ocufen]) are also effective.3 Physicians should consider ophthalmology consultation if opting for ocular steroid treatment. A pinguecula may be surgically excised for cosmetic reasons, if a lesion causes chronic irritation, or if an elevated lesion interferes with contact lenses.

A pinguecula should be differentiated from a pterygium. A pterygium is a triangular, fibrovascular overgrowth of connective tissue extending from the bulbar conjunctiva onto the cornea, whereas a pinguecula does not grow onto the cornea. Generally, pterygium excision is indicated if it continues to grow close to the visual axis.

About one third of conjunctival nevi are not pigmented and may mimic a pinguecula if situated on the temporal or nasal side of the limbus corneae. However, conjunctival nevi do not cause the acute inflammation seen in this patient. A subconjunctival foreign body is unlikely given the lack of exposure risk and marked pain. Viral conjunctivitis causes a more generalized conjunctival congestion that is more pronounced in the fornices.

Selected Differential Diagnosis

Condition Characteristics

Perilimbal nevus

May mimic a pinguecula if situated on the temporal or nasal side of the limbus corneae; does not cause inflammation

Pingueculitis

Localized inflammation surrounding a pinguecula; does not grow onto the cornea

Pterygium

Triangular, fibrovascular lesion usually on the nasal or temporal side of the limbus corneae; may grow onto the superficial layers of the cornea

Subconjunctival foreign body

Small foreign bodies may lodge under the conjunctiva; history of acute, severe eye pain and redness is common; certain occupations or hobbies increase risk (e.g., activities involving hammering or chiseling)

Viral conjunctivitis

Generalized conjunctival congestion that is more pronounced in the fornices

Selected Differential Diagnosis

View Table

Selected Differential Diagnosis

Condition Characteristics

Perilimbal nevus

May mimic a pinguecula if situated on the temporal or nasal side of the limbus corneae; does not cause inflammation

Pingueculitis

Localized inflammation surrounding a pinguecula; does not grow onto the cornea

Pterygium

Triangular, fibrovascular lesion usually on the nasal or temporal side of the limbus corneae; may grow onto the superficial layers of the cornea

Subconjunctival foreign body

Small foreign bodies may lodge under the conjunctiva; history of acute, severe eye pain and redness is common; certain occupations or hobbies increase risk (e.g., activities involving hammering or chiseling)

Viral conjunctivitis

Generalized conjunctival congestion that is more pronounced in the fornices

Address correspondence to Syed S. Azhar, MD, at sazhar@utmb.edu.Reprints are not available from the author.

Author disclosure: Nothing to disclose.

REFERENCES

1. Farjo QA, Sugar A. Conjunctival and corneal degenerations. In: Yanoff M, Duker JS, eds. Ophthalmology. 2nd ed. St. Louis, Mo.: Mosby, 2004.

2. Taylor HR, West SK, Rosenthal FS, Munoz B, Newland HS, Emmett EA. Corneal changes associated with chronic UV irradiation. Arch Ophthalmol. 1989;107:1481–4.

3. Frucht-Pery J, Siganos CS, Solomon A, Shvartzenberg T, Richard C, Trinquand C. Topical indomethacin solution versus dexamethasone solution for treatment of inflamed pterygium and pinguecula: a prospective randomized clinical study. Am J Ophthalmol. 1999;127:148–52.

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