T H E PINGUECULA*

SAUL SUGAR, M.D., AND SIDNEY KOBEENICK, M.D.

Detroit, Michigan

The pinguecula and its sequel, the ptery- subconjunctival hemorrhage occurs in the
gium, have always intrigued ophthalmologists area, or where iritic pericorneal injection is
because of the frequency with which they present, the pinguecula usually stands out by
present themselves clinically. Although the its avascularity and relative lack of involve­
lesions have been studied by many clinicians ment. At the edges of the pinguecula one
and pathologists,1-5 the pathogenesis of these usually finds varicosities of the vessels and
lesions is still not completely understood. As tortuosity and visible narrowing of the
the basis of this report 22 pingueculas and lumen. These vessel changes and absence
pterygiums that had been excised were of lymphatics suggest a degenerative change
studied histologically. In 19 of these the (figs. 1 and 2).
histologic findings were correlated with the On histologic examination, the principal
clinical appearance of the lesions as in­ lesions occurred in the subepithelial tissues.
dependently recorded in color transparencies
(table 1).
Pingueculas are usually bilateral and are
more often present nasally than temporally
(figs. 1 and 2). They consist of yellowish,
opaque, soft, slightly elevated tissue varying
considerably in size and appearance. In gen­
eral they are oval or round but tend to be tri­
angular with the base at the limbus. They
occupy the interpalpebral area and, depend­
ing on the case, usually lie just at the mid-
portion of the corneal margin; the lower
portion may extend for some distance along
the corneal circumference and for varying
distances into the conjunctiva. A pinguecula
may be clearly separated by a free area from
the cornea but may encroach here to form an
early pterygium. In most cases of pterygium
the pinguecula appears to be a component
of the head of the pterygium and is carried
onto the cornea as the pterygium extends.
The area of opacity in the pinguecula con­
sists grossly of single or multiple yellow
islands which cover the vessels and fill up the
space between the conjunctival epithelium
and sclera (fig. 1). In studies of the conjunc­
tival lymphatics with trypan blue6 it was
evident that the lymphatics did not extend Figs. 1 and 2 (Sugar and Kobernick). (1) Close-
up photograph of the eye from Case 18, showing a
into the opaque area. In instances where pinguecula with marked prominence of the blood
vessels on the nasal side (from Kodachrome). (2)
*From the Ophthalmology Section and the Divi­ Uncomplicated piguecula from Case 13 (from
sion of Laboratories, Sinai Hospital of Detroit. Kodachrome photograph).
341
342 S A U L SUGAR A N D S I D N E Y K O B E R N I C K

TABLE 1
CORRELATION OF CLINICAL AND PATHOLOGIC FINDINGS

Clinical Findings (from color photographs) Pathologic Findings

Case Patchy Epithelium Connective Tissue

No.
Diffuse Masses Conjunc-
Yellow Suggest­ Opacity Eleva­ tival Ir­ Elastic Cellular
Color ing tion ritation (cells thick) Hyalinized Hyper- Calcifi­ Infiltration
Calcifn Collagen plasia cation
1 +++ + +++ ++ 0 5-10 ++++ ++++ ++++ 0
2 0 0
3 + + + ++ 8-12 + + 0++++ 0
4
5-10
5-8 ++ ++++ 0
5 +++ ++ +++
6 +++ + +++ ++ ++ 10-15 ++ ++ 0+ + +
+ Focal Acute
0
7 0 0
8-15
5-8 + ++ 0
8 0 0 ++ + + 5-8 +++ +++ 0+ + + 0
9 +++ + + + + -f + Lymphs
+ + ++ ++ + 8-40 ++ ++++ ++ Subepithelial
10 0 0 0 3-8 0 0
11 0 0 + + 5-8 + ++++ 0
12 ++ ++ + ++ ++ 0 Moderate
++ + + ++ + + 5-20 ++ +++ vascularization
13 0 0
14 +++ +++ 0 8-15
5-6 ++ ++ 0
0
0
0
15 0 0 +++ ++++ 0
16 0 0 +++ + 0+
degeneration ++ ++++ 0
+ In elastic tissue
-j- + -\- Perivascu-
++ + degeneration ++ ++++ lar
17 5-20 +++ ++ ++ ?
18 0 0 0
19 +++ ++ 0+ 8-20
5-8 + ++++ 0 +
0
— +++ + + +++

The epithelial layers themselves showed no

significant alteration (fig. 7). Some cases
had a slight increase in the number of
squamous cells, from five to eight, but, in
general, the number and configuration of the
superficial conjunctival epithelium was nor­
mal (figs. 3, 4, 5, 6, 8, and 9). The layers
immediately subjacent to the epithelium
showed marked hyalinization of collagen (fig.
7). This was succeeded rapidly by a hyper-
plasia and distinct increase in elastic tissue
fibers (figs. 9 and 10), often increasing the
thickness of the subepithelial tissues 10 to
12 times the width of the epithelium and 20
times normal (fig. 7). In the elastic tissue
layers, clumps of irregularly degenerated ma­
terial, taking the elastic stain but also show­
ing evidence of basophilia—suggesting cal­
cification—were often found (figs. 7 and 8).
These were also deposited within the hyaline

Figs. 3 and 4 (Sugar and Kobernick). (3) Nor­

mal conjunctiva excised during a cataract opera­
tion. (Hematein, phloxine, and saffron; X90).
(4) Normal conjunctiva from same case as shown
in Figure 3, showing the delicacy of the tissue and a
large lymphatic channel, as well as the usual thick­
ness of the conjunctival squamous epithelium.
(Hematein, phloxine, and saffron, X370).
 THE PINGUECULA 343

(2) hyaline degeneration of collagen fibers,

(3) deposition of amorphous hyaline sub­
stance, and (4) the formation of concretions.
The histologic picture was first described
by Fuchs and later corroborated by Hub-
ner.5 The changes are particularly striking
in contrast with the normal structure of the
conjunctiva at the limbus where the tissue
consists of very loose connective tissue ar­
ranged around a lymphatic meshwork with
only an occasional elastic fiber in evidence
(fig. 4 ) .
DlSCUSSlOK
The degenerative nature of pingueculas
has been inferred by Hinnen 7 who found an
increasing incidence of pingueculas with ag­
ing. Of 462 individuals with normal eyes,
he found that in 48 patients over 70 years
of age, only two had no pinguecula. Some
few were present in those between 10 and
20 years of age.
The principal characteristic of the pingue­
cula histologically is the hyalinization of the
subepithelial tissue and the remarkable hy-
perelastosis. The normal conjunctiva con­
tains practically no elastic tissue and this
elastosis is the principal component of the
Figs. 5 and 6 (Sugar and Kobernick). (5) Nor­
mal conjunctiva and sclera from an excised eye. lesion. The hyalinization of the superficial tis­
(Hematein, phloxine, and saffron; X90). (6) Nor­ sue and ultimate calcification must be con­
mal conjunctival epithelium and subconjunctival con­ sidered to be derived from the increased
nective tissue of the visceral conjunctiva. Note
the extreme delicacy of the connective tissue pattern elastica that undergoes degeneration. It is
beneath the thin epithelium. ( F r o m same case as remarkable too that in uncomplicated pin­
in Figure S. Hematein, phloxine, and saffron; guecula there is a very small inflammatory
X370).
component. Little is known about elastosis.
layer. Their continuity with the hyperplastic Authorities on skin pathology cite only "hy-
elastic tissue was evident in some cases. Deep perelastosis cutis" as an instance of elastic
in the hyperplastic elastica the subconjuncti­ tissue disorders. However, it should be noted
val connective tissue resumed its normal vas- that this increase in elastic tissue may be
cularity and lymphatic channel content (fig. found adjacent to subacute inflammations or
7). A summary of the severity of the changes ulcerative inflammations of the mouth and
can be found in Table 1. of the skin. It is also noteworthy that in the
The attempt to predict the histologic pic­ so-called "collagen diseases" elastic tissue is
ture from clinical photographs, in those cases as much affected as is collagen by the funda­
where these were available, were unsuccess­ mental lesion.8
ful (table 1). To understand the pathogenesis of the
The histologic structure of pinguecula is pinguecula one must consider conjunctival
thus characterized by four processes: (1) anatomy and its relation to the physiology of
hypertrophy and hyperplasia of elastic fibers, lid blinking. When the lid blink reflex occurs,
344 SAUL SUGAR AND SIDNEY KOBERNICK

Figs. 7, 8, 9, and 10 (Sugar and Kobernick). (7) Excised pinguecula from Case 1. Note the thickening
of the entire conjunctiva, the comparative normality of the superficial squamous layer, the hyalinization
of the subepithelial connective tissue, calcium deposition, left center, and right the fragmentation of the
elastica continuous with the fragmentation of the elastica in the deepest layers. (Hematein, phloxine, and
saffron; X90). (8) A portion of the subepithelial layer in which there is focal calcification represented by
the black masses. (Hematein, phloxine, and saffron; X270). (9) A portion of the conjunctiva beneath
the epithelium in which there is marked fragmentation of elastica. It shows the hyalinization of the
subepithelial connective tissue. (Hematein, phloxine, and saffron; X270). (10) Same case showing the
deep layers of elastic tissue with fragmentation, with increase in elastica, reduplication and fragmentation
of elastic tissue fibers (Weigert's elastic stain).

the interpalpebral conjunctiva is squeezed portion is movable. Thus with the forma-
between the lids each time. The portion of tion of a pinguecula the involved interpal-
conjunctiva adjacent to the limbus is fixed pebral area, being partly fixed, receives the
to the underlying sclera while the remaining effect of the additional conjunctival tissue
 THE PINGUECULA 345

squeezed into the area from above and below The pathogenesis of the lesion may be con­
by the lids. Observation suggests that the sidered as originating with some stimulus,
nasal interpalpebral area is more firmly such as the physical motion of the lids against
pressed by the lids than the temporal portion the conjunctiva, along with age changes, al­
because of the greater curvature of the or- lergy, and possibly mild inflammatory fac­
bicularis nasally. This may explain the tors. This could imitate a degenerative and re-
greater frequency of pinguecula nasally. parative reaction, manifested by elastic tis­
In some instances the patient's attention sue formation and collagen-elastic degenera­
is called to a pinguecula when it begins to tion. The swelling associated with the latter
show signs of irritation. In these cases the process causes elevation of the tissue. The
epithelial surface shows increased whiteness process tends to be a continuing cycle since
in its center. Staining with fluorescein is the elevated tissue tends to more pressure
usually present. Histologically there is sub- by the lids and further reparative-degenera-
epithelial round-cell infiltration in addition tive reaction. In those cases where the volume
to the degenerative tissue usually present of the pinguecula is enough to involve the
in a pinguecula. It is doubtful that this in­ edge of Bowman's membrane, which seems
flammation is a major factor in the causa­ to act as a barrier, it is suggested that pteryg-
tion of pinguecula; however, it probably con­ ium has its beginning. As the pterygium
tributes its share. The simplest method of "grows," the pinguecula is carried onto the
treatment is removal of the total pingue­ cornea at its head.
cula area including the area of inflammation
down to the scleral surface. 28 West Adams Street (26).
REFERENCES
1. Fuchs, E.: Zur Anatomie der Pinguecula. Arch. f. Ophth., 38:143, 1891.
2. Lohlein, W.: Bindehaut. In Handbuch der speziellen Pathologischen Anatomie und Histologie.
(Henke, F., and Lubarsch, O.) Berlin, Springer, 1928, p. 147.
3. Bihler, W . : Ueber epitheliale Formen der Pinguecula. Klin. Monastsbl. f. Augenh., 37:77, 1899.
4. Best: Zur Pathologie der Geschwulste der Bindehaut. Klin. Monastsbl. f. Augenh., 38:553, 1900.
5. Hubner: Der Lidspaltenfleck. Arch. f. Augenh., 36:70, 1898.
6. Sugar, H. S., Riazi, A., and Schaffner, R.: The bulbar conjunctival lymphatics and their clinical
significance. Tr. Am. Acad. Ophth., 61:212, 1957.
7. Hinnen: Die Altersveranderungen des vorderen Bulbusabschnittes. Ztschr. f. Augenh., 45:137, 1921.
8. Duff, G. L.: The diffuse collagen diseases. Canad. M. A. J., 58:317, 1948.

BLUE SCLEROTICS SYNDROME SIMULATING BUPHTHALMOS*

DONALD P. TUCKER, M.D.
Boston, Massachusetts

A newborn infant with cloudy corneas he may be manifesting ocular complications

does not necessarily have congenital glau­
coma. Birth injuries may produce corneal
opacities due to ruptures in Descemet's mem­
brane. Hurler's disease and, rarely, luetic in­
terstitial keratitis may present with corneal
infiltrates in the newborn. If, in addition to
cloudy corneas, the patient has blue scleras,
*Presented at the Massachusetts Eye and Ear
Infirmary Alumni Meeting, April, 1958.
of the osteogenesis imperfecta syndrome.
Osteogenesis imperfecta is a genetically
transmitted disease characterized by defec­
tive mesodermal structures throughout the
body. Blue scleras are the most consistently
present sign of the syndrome. Fragile bones
and lax joint capsules leading to frequent
fractures and dislocations are present in
many; in addition, otosclerotic deafness de­
velops in about SO percent during the second