Review Article

Pinguecula
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Eduardo Arenas, Gioconda Armas, Alfredo Ramirez1

Department of Ophthalmology, El Bosque University, Bogotá, Colombia, 1Department of Ophthalmology, Clínica Oftalmológica De La Selva,
Tarapoto, Perú
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Abstract Pinguecula is a common disease in tropical countries however there are not so many published articles
regarding its aetiology, signs , symptoms and management . It seems that Ultraviolet rays play an
important role and it is one of the reasons that explain the prevalence in zones near the equator.
Pingüeculas behave different in the nasal than in the temporal side playing an important role in
the development of pterygium which explains the high incidence of its nasal location. Regarding
treatment and management , there are different approaches that will discussed in this mayor review.

Keywords: Corneal degeneration, ocular surface, pinguecula

Address for correspondence: Dr. Eduardo Arenas, Carrera 21 No. 100‑20 Piso 7, Bogotá, Colombia.
E‑mail: earenascable@gmail.com
Received: 31 May 2019, Accepted: 31 May 2019, Published Online: 26 September 2019

INTRODUCTION DEFINITION

Pinguecula, from the Latin “pinguis,” which means
“fatty,” [1] is a localized yellowish thickening of the
conjunctiva, prevalent in young adults living in the
tropics. The condition often goes unnoticed but could
increase progressively leading to chronic symptoms[2] or
could develop into a pterygium, resulting in particular
alterations to the cornea.[3] Reviewing the literature reveals
that few authors have discussed the clinical management
of patients with pinguecula, even though there is a
clear link between the incidence of this disorder and
repeated exposure to sunlight in areas, with high levels
of ultraviolet (UV) radiation. This is, without doubt, one
of the main causes of the appearance of such injuries
in the conjunctiva, which would give rise to the primary
pinguecula.
Pinguecula is a lesion that resembles a yellow spot or
bump in the conjunctival surface, which is located in the
interpalpebral region and appears first in the temporal side
and later in the nasal side. It is characterized by an avascular
central elevation surrounded by capillaries, and in the nasal
part, a similar lesion more punctate at mid‑distance between
the caruncle and the corneal limbus, in the axis of 180°.[4]
Depending on the size and elevation of the lesions, the
signs and symptoms increase, requiring ophthalmological
care.
ETIOLOGY
According to different authors, the main cause of
pinguecula formation is due to the influence of UV rays
on individuals living in areas with greater sun exposure.[5]

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10.4103/PAJO.PAJO_2_19 How to cite this article: Arenas E, Armas G, Ramirez A. Pinguecula. Pan
Am J Ophthalmol 2019;1:9.

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 Arenas, et al.: Pinguecula
In 1951, Bartlett studied the disease and found that people
in Mexico were particularly susceptible.[6] In addition,
they estimated a prevalence of 50% in adults living in
countries close to the equator. Other authors, such as
Panchapakesan et al.[7] and Mimura et al.,[8] mention a
prevalence that may vary between 22.5% and 70% in
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intertropical countries.
PHYSIOPATHOLOGY
In 1978, Arenas published a paper explaining how UV
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radiation could cause pinguecula and why this is more
symptomatic and aggressive when it is localized on the
nasal side of the eye.[9] It was explained that the temporal
side of the eye is more exposed to sunlight than the nasal
side, which is protected by the supraorbital notch and the
nose. UV rays hit the outer or temporal side of the eye
and by dispersion throughout the Bowman’s layer and the
Descemet membrane, emerging exactly 3 mm away from
the nasal limbus producing a chronic subconjunctival burn
in a punctual site, that initiates an inflammatory reaction of
the Tenon’s capsule. This gives rise to the nasal pinguecula,
and the elevation then initiates a Dellen phenomenon,
causing the conjunctiva to progressively cover the adjacent
dry spot. This slowly progresses toward the limbal area
initiating the classical pterygium, which continues growing
to the center of the cornea[10] [Figure 1]. The mechanism
of energy growth was described by Barraquer in 1964,[11]
who explained why the lesion tends to grow because of
this phenomenon. Fuchs in 1892[12] explained the important
role of UV rays, as an etiological factor in the formation
of these injuries.[13]
This type of pinguecula of solar origin is defined as primary
because there are cases in which it can be originated by the
presence of chronic irritations or the inclusion of foreign
bodies that would be named secondary pingueculas.[14]
Secondary pinguecula
Some authors mention that there may be other reasons for
the appearance of pinguecula in people exposed to foreign
bodies, as sometimes happens with workers handling
welding equipment. This was first described by Karay and
Horiguchi[15] and by Norm, in Norway.[16] These conditions
Figure 1: Theory of formation of the pinguecula[9]
2 The Pan American Journal of Ophthalmology | 2019
often occur as a consequence of foreign objects being
introduced into the conjunctiva and producing a focalized
inflammatory reaction. In Nigeria, Iyiade studied 405 welders,
50% of whom developed different types of pinguecula.[17]
Other authors have also reported similar findings.[18]
In 1937, Dimitri proposed a different theory for secondary
pinguecula; his theory associated the exposure to dust and
other foreign objects with the condition.[19] Other authors
have reported the existence of a link between the condition
and occupations with a greater risk of exposure to these
foreign objects as has been observed in motorcyclists.[20,21]
PREVALENCE
Asokan studied the incidence of the disease in the South
of India and found a prevalence of 11.3%.[22] Rezvan
studied its frequency in Iran and found a prevalence of
61%.[23] Le performed a study in Shanghai[24] and found
a prevalence of 75.57%. Viso also made a study in Spain
and found a prevalence of 47.9%.[25] They also found a
prevalence of 5.9% for the pterygium. In Teheran, the
prevalence of pinguecula was 22.5%,[25] and in Nigeria,
Iyiade, found a prevalence of 50.1% (much larger than
pterygium 17.5%).[17]
In Latin America, there are very few studies available
on the prevalence of this disorder. In Colombia, a
prevalence of 11% was found in natives of the Riosucio
region and 7% in the Choco region. This study also
found a prevalence of 14.7% in the Afro‑Colombian
population.[26] Finally, Esposito found a prevalence of
32.1% in Patagonia (Argentina).[27]
As mentioned before, the prevalence of pinguecula is in
areas with greater exposure to UV radiation.[28,29] However,
other studies such as those of Nakaishi, determined that
there may be other factors creating a close link between
occupation and the type of work and UV exposure for
the prevalence of pinguecula.[30] Taylor found a higher
prevalence in motorcycle police officers of 37.7%.[31] In
Colombia, Cortes found a prevalence of 37.4% in workers
exposed to cement dust.[32]
The pinguecula is also more prevalent in aging populations.[33]
Other authors found that the prevalence was directly linked
to age in people over 40.[14,34]. Le found this in people over 50.
[25]
Mimura found that people aged 40 and above are at a
higher risk of developing the condition.[35] Regarding gender,
the incidence was higher in men tahn in women.[17,23,25] Other
authors also found increased prevalence in rural areas and
no differences among genders.[27]
 Arenas, et al.: Pinguecula
Dysfunction of the tear film is another risk factor associated
with the formation of pinguecula. Balogun found an
association between alterations of the lacrimal film and the
formation of pterygium, but not with pinguecula in breakup
time (BUT) measurement.[36] Other authors, such as Oguz,
showed that the BUT is shorter in people with pinguecula
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than in healthy people due to an irregularity in the ocular
surface, demonstrating that if the tear layer is thinned by
an irregularity located in the epithelium of the surface. The
flow of lipids will increase considerably and with it the
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possibility of a rapid and highly focalized contamination
of lipids on the mucus layer, causing a hydrophilicity of the
tear film that will break immediately on these hydrophobic
surfaces, destabilizing the tear film.[37] Hashemi et al.[38] and
Siak et al.[39] both found, in contrast to the pterygium, a
statistically significant relationship between the dysfunction
of the Meibomian glands and pinguecula, because it can
alter the function of the lacrimal layer producing an increase
in the dysfunction of Meibomian glands.
Regarding diabetes, smoking, and alcohol consumption,
studies show a relationship between these diseases and
the appearance of pinguecula,[40] while Asokan, in South
India, found no association between these diseases and
the appearance of pinguecula.[22] Ozer studied the link
between pinguecula and thyroid orbitopathy, finding a
higher prevalence in the group with thyroid orbitopathy.[41]
The use of contact lenses may be associated with the
appearance of pinguecula produced by a microtrauma
mechanism. Mimura found a higher prevalence in a group
of patients using rigid contact lenses.[42] In another study
by the same authors, they found an associated risk between
conjunctivochalasis and pinguecula, but this was challenged
by Hashemi who found an inverse link between these two
entities and blepharitis.[43]
Some authors have found a link between pinguecula and
systemic diseases such as psoriasis.[44,45] Patients with
erythrodermic psoriasis and Sjogren’s syndrome are even
more at risk.[46]
SIGNS AND SYMPTOMS
Most publications describe pinguecula as asymptomatic;[47]
however, there are patients reporting symptoms such as the
sensation of a foreign body, tearing, pain or discomfort,[48,49]
causing reddening, itching, and a sprain sensation.[50] Some
studies suggest that pinguecula causes instability of the tear
film,[51] though it is not clear so far if dry eye causes changes
in the conjunctiva and later formation of the pinguecula, or
if the pinguecula actually causes instability of the tear film.[52]
The Pan American Journal of Ophthalmology | 2019
Changes in visual acuity are seldom associated with
pinguecula being a casual finding in patients presenting
symptoms of ocular surface disturbance.[3] In the Tehran
Eye Study, Fotouhi found that 11.5% of people with
pinguecula showed <20/40 visual acuity, compared to 4.3%
of people without. However, when age was accounted for
in this study, the correlation disappeared.[27] Pham et al.[53]
and Lim et al.[54] found a significant risk of developing
cataracts in patients with pinguecula.
The diagnosis of pinguecula is fundamentally clinical and is
made based on the medical history and ocular examination.
Kim analyzed the autofluorescence of pinguecula using
a cobalt‑blue filter and an additional yellow filter on a
slit‑lamp and found two patterns: (1) round and elevated
lesions with tortuous vessels and no vessel invasion and (2)
flat and bizarre lesions with vessel invasion.[55] Utine also
analyzed the autofluorescence of pinguecula, but they used
a scanning laser ophthalmoscope. The technique allowed
them to distinguish pinguecula from other lesions and they
obtained “well‑defined autofluorescence” over a larger area
than “the extent of visible pinguecula.”[56] Ip found Fuchs
spots to be an early sign of UV radiation damage on the
conjunctiva. These spots are precursors of lesions such as
pinguecula and pterygium and are found in 95% of eyes
with pinguecula and also in the contralateral eye.[14] Nanji
et al.[57] and Demirci and Steen[58] used high‑resolution
optical coherence tomography and found similarities
between pinguecula and pterygium. They both showed mild
epithelial hyperreflectivity and slightly engrossed normal
epithelia. In addition, the authors found a mass of dark, sub
epithelial tissue near the limbus in patients with pinguecula.
MANAGEMENT
Many authors agree that pinguecula does not require
treatment, unless the patient shows symptoms of
inflammation.[59] In these cases, the use of lubricants and
topical corticosteroids is recommend.[36] In 1997 and 1999,
Frucht compared the effect of topical formulations in
groups treated with 0.1% topical indomethacin and with
0.1% topical dexamethasone phosphate against a group
treated with a placebo. They found that in the groups
treated with the topical formulations, most of the symptoms
improved.[60] In 2014, Arenas proposed a new local therapy
for symptomatic pinguecula. The treatment consisted in
the application of depot betamethasone directly into the
lesion, with positive results and improvement in signs and
symptoms.[61]
Ahn compared surgical management of pinguecula
with the use of argon laser therapy. They found that
3
 Arenas, et al.: Pinguecula
laser therapy produced comparable results to surgical
treatment. They also studied BUT a year after treatment
and found improvement of symptoms in patients treated
with laser therapy.[62] Napoli also used laser therapy and
highlighted the safety of the procedure regarding bleeding
compared with surgical management. In addition, Shin
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reported the effectiveness of laser therapy because it
avoids subconjunctival hemorrhage[63] without causing
subconjunctival hemorrhage. Jung also demonstrated
the esthetic result of excision of the pinguecula with
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conjunctival autograft, a very safe and highly effective
procedure, with regression of vascularization.[64]
HISTOLOGY
Different histological changes are observed in pinguecula
including atrophy, hyperplasia, metaplasia, dysplasia,
subepithelial hyalinized collagen, and elastosis.[65,66] Peiretti
suggests the hypothesis that this disorder has a proliferative
component, demonstrating an overexpression of two
genes associated with the metabolism of low‑density
lipoprotein‑receptor cholesterol, and HMG‑CoA‑R RNAm,
in comparison with a healthy conjunctiva,[67] even in the
presence of metallothionein.[68] Alterations to gene p53 are
also suspected to cause the disorder. Authors have suggested
how UV rays can cause mutations in gene p53 that alter
the metabolism of cholesterol, leading to the disorder.[69]
Hyung found “depositions of eosinophilic and amorphous
materials in the subepithelial layer of the conjunctiva and
degeneration of the collagen fibers in the conjunctival
stroma” via autofluorescence imaging.[55] Chen determined
that the pinguecula is an abnormal differentiation
condition characterized by squamous metaplasia with
proliferation toward the limbal border.[70] The progression
from pinguecula to pterygium was documented by
Chapman‑Smith and others from remoter times, suggesting
that pinguecula is a condition of abnormal differentiation
characterized by squamous metaplasia and proliferation
of cells toward the limbal ring.[71] Degenerative changes in
the components of both disorders are believed to lead to
inflammation; the lesion can result from a combination of
elastodysplasia and posterior elastodystrophy.[72]
CONCLUSIONS
Few authors have addressed the prevalence of pinguecula
in different parts of the world where its incidence is
high. Chronic symptoms, unesthetic appearance, and the
problems it represents for users of contact lenses, suggest
more attention is needed for this condition.
Financial support and sponsorship
Nil.
4 The Pan American Journal of Ophthalmology | 2019
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Sugar S, Koberniek S. The pinguecula. Am J Ophthalmol 1960;50:341‑5.
2. Norn MS. Prevalence of pinguecula in Greenland and in Copenhagen,
and its relation to pterygium and spheroid degeneration. Acta
Ophthalmol (Copenh) 1979;57:96‑105.
3. Bell A. Pinguecula. J Vis Commun Med 2006;29:82‑3.
4. Reid TW, Dushku N. Pterygia and limbal epithelial cells: Relationship
and molecular mechanisms. Prog Retin Eye Res 1996;15:297‑329.
5. Yam JC, Kwok AK. Ultraviolet light and ocular diseases. Int
Ophthalmol 2014;34:383‑400.
6. Bartlett RE, Mumma CS. Etiologic theories, methods of treatment,
and results. Calif Med 1951;74:263‑6.
7. Panchapakesan J, Hourihan F, Mitchell P. Prevalence of pterygium and
pinguecula: The blue mountains eye study. Aust N Z J Ophthalmol
1998;26 Suppl 1:S2‑5.
8. Mimura T, Obata H, Usui T, Mori M, Yamagami S, Funatsu H, et al.
Pinguecula and diabetes mellitus. Cornea 2012;31:264‑8.
9. Arenas E. Etiopathogenesis of Pinguecula and pterigyum. Palestra
Oftalmol Panam 1978;2:28‑31.
10. Archila EA, Arenas MC. Etiopathology of pinguecula and pterigium.
Cornea 1995;14:543‑4.
11. Barraquer JI. Etiology and pathogenesis of pterygium and Dellen.
Arch Soc Amer Oftalmol Optom 1964;5:49-60.
12. Fuchs E. About Pterigyum Graefes Arch Ophthalmol 1892;38:1‑89.
13. Moran DJ, Hollows FC. Pterygium and ultraviolet radiation: A positive
correlation. Br J Ophthalmol 1984;68:343‑6.
14. Ip MH, Chui JJ, Tat L, Coroneo MT. Significance of Fuchs flecks in
patients with pterygium/Pinguecula: Earliest indicator of ultraviolet
light damage. Cornea 2015;34:1560‑3.
15. Karai I, Horiguchi S. Pterygium in welders. Br J Ophthalmol
1984;68:347‑9.
16. Norn M, Franck C. Long‑term changes in the outer part of the eye in
welders. Prevalence of spheroid degeneration, pinguecula, pterygium,
and corneal cicatrices. Acta Ophthalmol (Copenh) 1991;69:382‑6.
17. Iyiade A, Omotoye Olusola J. Pattern of eye diseases among welders
in a Nigeria community. Afr Health Sci 2012;12:210‑6.
18. Davies KG, Asanga U, Nku CO, Osim EE. Effect of chronic exposure
to welding light on calabar welders. Niger J Physiol Sci 2007;22:55‑8.
19. Dimitry TJ. Dust factor in production of Pterygium. Am J Ophthamol
1937;20:40‑5.
20. Nakaishi H, Yamamoto M, Ishida M, Someya I, Yamada Y. Pingueculae
and pterygia in motorcycle policemen. Ind Health 1997;35:325‑9.
21. okayTaiwo OA, Beki‑bele CO, Adeoye AO, Adegbehingbe BO,
Onakpoya OH, Olateju SO, et al. Prevalence and pattern of eye
disorders among commercial motorcycle riders in Ile‑Ife, Osun state.
Niger Postgrad Med J 2014;21:255‑61.
22. Asokan R, Venkatasubbu RS, Velumuri L, Lingam V, George R.
Prevalence and associated factors for pterygium and pinguecula in a
South Indian population. Ophthalmic Physiol Opt 2012;32:39‑44.
23. Rezvan F, Khabazkhoob M, Hooshmand E, Yekta A, Saatchi M,
Hashemi H, et al. Prevalence and risk factors of pterygium: A systematic
review and meta‑analysis. Surv Ophthalmol 2018;63:719‑35.
24. Le Q, Xiang J, Cui X, Zhou X, Xu J. Prevalence and associated factors
of pinguecula in a rural population in Shanghai, Eastern China.
Ophthalmic Epidemiol 2015;22:130‑8.
25. Fotouhi A, Hashemi H, Khabazkhoob M, Mohammad K. Prevalence
and risk factors of pterygium and pinguecula: The Tehran eye study.
Eye (Lond) 2009;23:1125‑9.
26. Buchelli AI, Corva DC. Prevalence of pathologies of anterior
segment in afro Colombiam population 2009: Optometry facuty
Available From: http/handle net/10185/8559.
 Arenas, et al.: Pinguecula
27. Esposito E, Correa L, Suarez MF. Comparative study between climatic
spheroidal keratopaty with pinguecula and pterigyum in the Patagonia
Region Asociaton for research in Vision Argentina 2014.
28. Perkins ES. The association between pinguecula, sunlight and cataract.
Ophthalmic Res 1985;17:325‑30.
29. Garg A, Loosemore M. Pinguecula following psoralen and ultraviolet
A therapy. J Am Acad Dermatol 2007;57:177‑8.
30. Nakaishi H, Yamamoto M, Ishida M, Someya I, Yamada Y. Pingueculae
Downloaded from http://journals.lww.com/pajo by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
and pterygia in motorcycle policemen. Ind Health 1997;35:325‑9.
31. Taylor HR, West SK, Rosenthal FS, Munoz B, Newland HS,
Emmett EA, et al. Corneal changes associated with chronic UV
irradiation. Arch Ophthalmol 1989;107:1481‑4.
32. Cortés S. Idrovo A. Prevalence of pterigyum and pinguecula in
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 01/05/2024
workers with a cement Mine in Bogota. Rev Salud Pública
2001;3:65‑73.
33. Rezvan F, Hashemi H, Emamian MH, Kheirkhah A, Shariati M,
Khabazkhoob M, et al. The prevalence and determinants of pterygium
and pinguecula in an urban population in Shahroud, Iran. Acta Med
Iran 2012;50:689‑96.
34. Ten Doesschate J, Fischer FP. Some statistical observations on the
frequency of occurrence of pterygium and pinguecula in relation to
age. Ophthalmologica 1949;118:137‑42.
35. Mimura T, Usui T, Obata H, Yamagami S, Mori M, Funatsu H, et al.
Severity and determinants of pinguecula in a hospital‑based population.
Eye Contact Lens 2011;37:31‑5.
36. 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;24:162‑6.
37. Oguz H, Karadede S, Bitiren M, Gurler B, Cakmak M. Tear functions
in patients with pinguecula. Acta Ophthalmol Scand 2001;79:262‑5.
38. Hashemi H, Rastad H, Emamian MH, Fotouhi A. Meibomian gland
dysfunction and its determinants in Iranian adults: A population‑based
study. Cont Lens Anterior Eye 2017;40:213‑6.
39. Siak JJ, Tong L, Wong WL, Cajucom‑Uy H, Rosman M, Saw SM, et al.
Prevalence and risk factors of meibomian gland dysfunction: The
Singapore Malay eye study. Cornea 2012;31:1223‑8.
40. Malekifar P, Esfandiari H, Behnaz N, Javadi F, Azish S, Javadi MA,
et al. Risk factors for pterygium in Ilam province, Iran. J Ophthalmic
Vis Res 2017;12:270‑4.
41. Ozer PA, Altiparmak UE, Yalniz Z, Kasim R, Duman S. Prevalence of
pinguecula and pterygium in patients with thyroid orbitopathy. Cornea
2010;29:659‑63.
42. Mimura T, Usui T, Mori M, Yamamoto H, Obata H, Yamagami S, et al.
Pinguecula and contact lenses. Eye (Lond) 2010;24:1685‑91.
43. Hashemi H, Rastad H, Emamian MH, Fotouhi A. Conjunctivochalasis
and related factors in an adult population of Iran. Eye Contact Lens
2018;44 Suppl 1:S206‑9.
44. Omar SS, Helaly HA. Prevalence of ocular findings in a sample of
Egyptian patients with psoriasis. Indian J Dermatol Venereol Leprol
2018;84:34‑8.
45. Lima FB, Abalem MF, Ruiz DG, Gomes Bde A, Azevedo MN,
Moraes HV Jr., et al. Prevalence of eye disease in Brazilian patients
with psoriatic arthritis. Clinics (Sao Paulo) 2012;67:249‑53.
46. de Roux‑Serratrice C, Conrath J, Serratrice J, Granel B, Disdier P,
Weiller PJ, et al. Pinguecula and Sjögren’s syndrome: Two cases. Lupus
2001;10:368‑9.
47. Jaros PA, DeLuise VP. Pingueculae and pterygia. Surv Ophthalmol
1988;33:41‑9.
48. Dong N, Li W, Lin H, Wu H, Li C, Chen W, et al. Abnormal epithelial
differentiation and tear film alteration in pinguecula. Invest Ophthalmol
Vis Sci 2009;50:2710‑5.
49. Kaji Y, Oshika T, Amano S, Okamoto F, Koito W, Horiuchi S, et al.
Immunohistochemical localization of advanced glycation end products
in pinguecula. Graefes Arch Clin Exp Ophthalmol 2006;244:104‑8.
50. Frucht‑Pery J, Solomon A, Siganos CS, Shvartzenberg T, Richard C,
Trinquand C, et al. Treatment of inflamed pterygium and pinguecula
The Pan American Journal of Ophthalmology | 2019
with topical indomethacin 0.1% solution. Cornea 1997;16:42‑7.
51. Napoli PE, Sanna R, Iovino C, Fossarello M. Resolution of
pinguecula‑related dry eye disease after argon laser photocoagulation.
Int Med Case Rep J 2017;10:247‑50.
52. Yokoi N, Inatomi T, Kinoshita S. Surgery of the conjunctiva. Dev
Ophthalmol 2008;41:138‑58.
53. Pham TQ, Wang JJ, Rochtchina E, Mitchell P. Pterygium, pinguecula,
and 5‑year incidence of cataract. Am J Ophthalmol 2005;139:1126‑8.
54. Lim R, Mitchell P, Cumming RG. Cataract associations with pinguecula
and pterygium: The blue mountains eye study. Am J Ophthalmol
1998;126:717‑9.
55. Kim TH, Chun YS, Kim JC. The pathologic characteristics of
pingueculae on autofluorescence images. Korean J Ophthalmol
2013;27:416‑20.
56. Utine CA, Tatlipinar S, Altunsoy M, Oral D, Basar D, Alimgil LM,
et al. Autofluorescence imaging of pingueculae. Br J Ophthalmol
2009;93:396‑9.
57. Nanji AA, Sayyad FE, Galor A, Dubovy S, Karp CL. High‑resolution
optical coherence tomography as an adjunctive tool in the diagnosis
of corneal and conjunctival pathology. Ocul Surf 2015;13:226‑35.
58. Demirci H, Steen DW. Limitations in imaging common conjunctival
and corneal pathologies with Fourier‑domain optical coherence
tomography. Middle East Afr J Ophthalmol 2014;21:220‑4.
59. Hill JC, Maske R. Pathogenesis of pterygium. Eye (Lond) 1989;3 (Pt
2):218‑26.
60. 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.
61. Arenas‑Archila E, Arellano K, Muñoz‑Sarmiento D. Intra‑lesional
injection of betamethasone for the treatment of symptomatic
pinguecula. Arch Soc Esp Oftalmol 2014;89:408‑10.
62. Ahn SJ, Shin KH, Kim MK, Wee WR, Kwon JW. One‑year outcome
of argon laser photocoagulation of pinguecula. Cornea 2013;32:971‑5.
63. Shin JY, Khang MH, Han YK, Kwon JW. Case of argon laser
photoablation of pinguecula. Clin Exp Ophthalmol 2010;38:735‑6.
64. Jung S, Kwon JW, Hwang HS, Chuck RS. Vascular regression after
pinguecula excision and conjunctival autograft using fibrin glue. Eye
Contact Lens 2017;43:199‑202.
65. Soliman W, Mohamed TA. Spectral domain anterior segment optical
coherence tomography assessment of pterygium and pinguecula. Acta
Ophthalmol 2012;90:461‑5.
66. Raizada IN, Bhatnagar NK. Pinguecula and pterygium (a
histopathological study). Indian J Ophthalmol 1976;24:16‑8.
67. Peiretti E, Dessì S, Putzolu M, Fossarello M. Hyperexpression of
low‑density lipoprotein receptors and hydroxy‑methylglutaryl‑coenzyme
A‑reductase in human pinguecula and primary pterygium. Invest
Ophthalmol Vis Sci 2004;45:3982‑5.
68. Tsironi S, Ioachim E, Machera M, Aspiotis M, Agnanti N, Psilas K,
et al. Presence and possible significance of immunohistochemically
demonstrable metallothionein expression in pterygium versus
pinguecula and normal conjunctiva. Eye (Lond) 2001;15:89‑96.
69. Dushku N, Hatcher SL, Albert DM, Reid TW. P53 expression and
relation to human papillomavirus infection in pingueculae, pterygia,
and limbal tumors. Arch Ophthalmol 1999;117:1593‑9.
70. Chen CY, Huang EJ, Kuo CN, Wu PL, Chen CL, Wu PC, Wu SH,
King YC, Lai CH. The epidemiology of patients with pterygium in
southern Taiwanese adults: The Chiayi survey. Taiwan J Ophthalmol
2013;3:58‑61.
71. Chapman‑Smith JS. Pterygium treatment with triethylene
thiophosphoramide. Aust N Z J Ophthalmol 1992;20:129‑31.
72. Austin P, Jakobiec FA, Iwamoto T. Elastodysplasia and elastodystrophy
as the pathologic bases of ocular pterygia and pinguecula.
Ophthalmology 1983;90:96‑109.
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