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Bilateral Punctal Foreign Body Granulomas Secondary to Multiple Retained Punctal Plugs

Wei Liu, Xiao B.S.*; Alawad, Mouyed M.D.; Shinder, Roman M.D., F.A.C.S.*

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Ophthalmic Plastic and Reconstructive Surgery: January/February 2020 - Volume 36 - Issue 1 - p e25
doi: 10.1097/IOP.0000000000001391
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A 61-year-old female presented with a 3-month history of symmetric pink soft tissue masses from both inferior puncta (Fig. A). She had a history of dry eye and placement of 4 punctal plugs in each inferior punctum by her ophthalmologist. Bilateral excision and canaliculotomy revealed 4 retained punctal plugs in each inferior canaliculus (Fig. B). Histopathology (Fig. C,D, Hematoxylin & Eosin ×200, Hematoxylin & Eosin ×400) showed granulation tissue composed of fibroblasts, a mixed inflammatory infiltrate of neutrophils and lymphocytes, capillaries with reactive endothelial cells (arrowheads), and refractile foreign bodies (asterisk) surrounded by multinucleated giant cells (arrows). The findings confirmed bilateral punctal foreign body granulomas from multiple retained punctal plugs. The patient was given tobramycin/dexamethasone eyedrop 3 times daily to both eyes for 1 week following surgery. The patient had clinical resolution without recurrence or epiphora over a 15-month follow up.

Punctal foreign body granuloma from retained punctal plugs. A, Left inefrior punctal mass. B, Punctal plugs retrieved during canaliculotomy. C, Histopathology revealed mixed inflammatory cells and reactive endothelial cells. D, High magnification disclosed refractive foreign bodies surrounded by multinucleated giant cells.

Punctal plugs are frequently used in the management of dry eye, and proper sizing is important to decrease complications. While efficacious, they can be associated with local irritation, infection, extrusion, migration, pyogenic granuloma, punctal scarring, and epiphora. To the authors’ knowledge, the development of foreign body granulomas after punctal plug placement has yet to be described. The pathogenesis of foreign body granulomas from punctal plugs is uncertain, but granuloma reactions generally occur as a result of immunologic responses against foreign antigens. It is plausible that past reports describing pyogenic granulomas related to punctal plugs may in fact have been foreign body granulomas as the diagnoses were not histologically confirmed in some reports. Clinicians should therefore size and place punctal plugs carefully and be aware of the possibility of foreign body granuloma from retained plugs.

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