Pingueculitis in psoriasis patient on secukinumab – An unreported adverse event

Dear Editor,

Psoriasis is a chronic, recurrent, immune-mediated inflammatory disorder, affecting 0.44-2.8% of Indian population.¹ Ocular manifestations are seen in around 50- 60% of patients affected with psoriasis; keratoconjunctivitis sicca and blepharitis are common. Other changes include conjunctivitis, uveitis, punctate keratitis, pinguecula, cataract, glaucoma, corneal abscess, pterygium formation, abnormalities of retinal vascularisation or rarely, pigment dispersion syndrome.² FDA adverse event reporting system has reported new onset uveitis in 1.5% patients on secukinumab.³ Pingueculitis is a non-specific inflammatory condition affecting the pinguecula, characterised by redness, irritation and discomfort. We report a case of pingueculitis, an unreported adverse event, in a psoriasis patient treated with secukinumab.

A 33-year-old man with a 5-year history of chronic plaque psoriasis, previously treated with methotrexate, cyclosporine and acitretin, presented with flare involving 30% body surface area and psoriasis area and severity index (PASI) score of 14.2. Baseline investigations were within normal limits. He was treated with injection secukinumab, 300 mg subcutaneously, weekly for 5 weeks and monthly thereafter along with supportive treatment. He achieved complete clearance at 5 weeks and maintained remission on monthly dosages [Figures 1a and b]. However, after 44 weeks, the patient developed redness and swelling on the medial side of his left eye, accompanied by foreign body sensation, 48 hours after secukinumab injection. Ophthalmology review revealed engorged and tortuous vessels superficial to the sclera, with slit lamp examination showing the lesion to be raised above the ocular surface [Figures 2a-c]; visual acuity, corneal and retinal examination were within normal limits. Schirmer’s test revealed normal tear film breakup time. He was diagnosed with pingueculitis of left eye and managed with a tapering course of topical steroid and lubricant eye drops.

Close

Figure 1: Clinical image showing a) extensive psoriasis on back before secukinumab treatment, b) resolution of psoriasis on the back after 4 weeks of injection secukinumab.

Export to PPT

Close

Figure 2a: Clinical image of left eye showing erythema on medial side not crossing corneoscleral junction.

Export to PPT

Close

Figure 2b: Slit lamp examination shows the lesion is raised above the ocular surface suggestive of pingueculitis.

Export to PPT

Close

Figure 2c: Image in green light for better visualisation of vasculature. The image is consistent with the diagnosis of pingueculitis.

Export to PPT

Pinguecula is a yellowish to brown protruding lesion in the conjunctiva, present asymmetrically on either side of the cornea. It does not cross the corneoscleral junction. Pterygium is a close differential diagnosis, that appears as a wing-shaped overgrowth of the fibrovascular tissue on the cornea, crossing the corneoscleral junction and may warrant surgical excision due to cosmetic reason or hinderance in optical function. In our patient, no eye surgery had been undertaken and the left eye showed an inflamed protruding mass nasal to the corneoscleral junction but not involving or crossing it. Episcleritis and scleritis are other differential diagnoses, but show more diffuse involvement and are more symptomatic as compared to pingueculitis. Our patient developed a similar lesion 24- 48 hours after every injection, over the next three months. The maintenance dose was continued and the side effect was managed without discontinuing the treatment. The intensity of lesions reduced slowly despite treatment continuation. The presence of pinguecula in his eye was brought to our notice only after he developed redness in his eye. Naranjo’s causality scale score of 8 suggested that adverse event due to drug was ‘probable’ [Table 1]. Other trigger factors such as dry eyes, smoking and allergic conjunctivitis were ruled out by history and clinical examination.

Ocular involvement in psoriasis can be due to direct ocular involvement or an immune-mediated process, leading to uveitis in patients with psoriatic arthritis.⁴ Treatment can also have ocular side effects; acitretin may cause dry eye, and phototherapy can result in cataract. Furthermore, biological therapies, such as anti-tumour necrosis factor-alpha (TNFα) and interleukin 17 (IL-17) inhibitors may also cause ocular manifestations.⁵ Anterior, intermediate and posterior uveitis, scleritis and orbital myositis have been reported with TNFα inhibitors. Additionally, other ocular adverse events noted are blepharitis, ectropion, optic neuritis, visual impairment, diplopia, endophthalmitis, sarcoid-like granulomatosis, panuveitis and retinal vasculitis.⁶ Real-world studies with secukinumab have reported adverse event rates of 7.2% to 61%, with most adverse effects occurring within 4 months and median onset duration of 56 days after treatment initiation.Th17 cells are crucial for host defence against common pathogens such as candida and staphylococcus. They also drive inflammatory response and have been implicated in dry eyes and uveitis. IL17 blockers help in treatment of diseases caused by overactive Th17 pathway.⁷ However, paradoxical reactions can occur after institution of IL17 blockers, as seen in our case. This may result from imbalance of cytokine profile and over expression of TNFα and IFNγ.

Our patient tolerated treatment for 44 weeks without adverse effects but subsequently developed recurrent pingueculitis lasting 4 months, occurring 24-48 hours after each dose. A comprehensive literature search was conducted using multiple electronic databases including PubMed, EMBASE and Scopus from their inception until August 2025. The search strategy utilised combinations of keywords such as ‘secukinumab,’ ‘psoriasis,’ ‘ocular adverse events,’ and ‘pingueculitis.’ No previous reports of pingueculitis associated with secukinumab therapy were identified through this systematic search. Pingueculitis represents a previously unreported adverse effect of secukinumab and we managed the condition symptomatically without interrupting treatment.