A 33-year-old white male called for an urgent appointment prompted by a coworker who became alarmed at his red right eye. He had no visual complaints. The patient indicated in his history that he hadn't previously had a comprehensive eye examination other than screening examinations while in the military service. The patient had been discharged from the Army within the last nine months following two oneyear tours in Iraq. He did admit to reading late into the previous night. The medical and medication histories were non-contributory. Visual acuity was 20/20 in each eye, and refraction revealed that he needed no correction.

Examination of the lids revealed anterior and posterior blepharitis. The cornea was clear without staining with the exception of a 2mm x 2mm irregular patch nasally that correspondedto his conjunctival redness. This area was juxtaposed to an inflamed pinguecula on the nasal conjunctiva. The conjunctiva was otherwise unremarkable. Examination of the anterior chamber, iris and anterior lens were similarly unremarkable in the right eye. The left eye showed similar findings but to a much lesser degree.

Inflamed pinguecula may result in significant injection - in this case to the point of observation by a coworker.

For this patient several treatment options were available. I chose to attack the blepharitis with Ilotycin (Erythromycin Ophthalmic Ointment, USP, 0.5%) applied to the inferior culde-sac and lids twice per day. My purpose was to offer some cushioning function from the ointment vehicle for the cornea and conjunctiva as well as to attack the blepharitis.

This patient's blepharitis responded well to the Ilotycin treatment within two weeks. His pinguecula was still inflamed but not as much. I decided to have him maintain ocular surface comfort with tear supplements applied regularly.

Alternative treatment strategies for inflamed pinguecula range from simply observing the patient to prescribing steroid drops. Others have recommended lubrication alone, as I chose in this case. You may consider anti-inflammatory drops in the context of the chronicity of the condition. Is the patient a steroid responder? If so, consider a non-steroidal antiinflammatory drug as an alternative. You might also consider a lower dose of one of the so-called soft steroids (for example Alrex, loteprednol etabonate ophthalmic suspension 0.2%, Bausch & Lomb). Do think about the patient's financial resources when making such decisions.

It's essential that you monitor the patient with any of these potential management options. I like to see the blepharitis patients for follow up in two to three weeks to monitor their progress and change to another strategy if my initial one fails. Similarly, monitoring intraocular pressure is essential when using steroid drops. Loteprednol has less potential to raise IOP in steroid responders within a six-week interval of use. Nonetheless, with any chronic condition you must consider the potential adverse effects of longterm use.