Dry Eye Dx and Tx

Pyogenic Granuloma with Silicone Plug Use

By Amber Gaume Giannoni, OD, FAAO

The modern use of punctal occlusion in dry eye management began almost 40 years ago, and it has proven to be a safe, effective, and reversible therapy (Freeman, 1975; Balaram et al, 2001; Tai et al, 2002; Baxter and Laibson, 2004). However, potential complications do exist, including allergy, infection, internal migration, spontaneous extrusion, and granuloma formation (Pflugfelder et al, 2007). Additionally, a patient may actually become more symptomatic if plugs are inserted prior to adequate inflammatory control because of increased contact time of pro-inflammatory cytokines with the ocular surface due to decreased tear clearance (Pflugfelder et al, 2007). As with any surgical procedure, careful patient selection and monitoring is necessary to ensure ultimate success.

A Case Study

A patient presented to our Dry Eye Service with complaints of inferior-nasal irritation near the right lower lid. She reported that silicone plugs had been inserted three years prior for dry eye, with no complications until now. Upon close inspection, the plug had partially extruded from the lower punctum and was rubbing on the inferior bulbar conjunctiva.

After several failed attempts to re-seat the plug, we decided removal was necessary. This proved challenging, as the cap disintegrated, leaving behind the stalk within the punctal opening. Several additional attempts were made to remove the remaining plug material, but tissue was holding it in place; whenever we tugged, the plug would only go so far before the tissue snapped it back from the forceps into place.

We informed the patient that we suspected pyogenic granuloma formation, and that the plug required surgical removal.

Pyogenic Granulomas

Pyogenic granulomas are benign vascular tumors that typically form in response to chronic irritation or injury. A rare, but potential complication of “permanent” punctal plugs, they often require surgical intervention and can re-grow if not completely removed.

The incidence of pyogenic granulomas associated with punctal plugs is challenging to pinpoint, as most cases are documented as individual accounts. However, one major review conducted in 2012 reported a frequency of between 2.5% and 6%, depending on the type of plug (Bourkiza and Lee, 2012).

In terms of causative factors, one observational case series reviewed 903 same-brand silicone plug insertions during a four-year period and found that sharper edges and larger plug size appear to be associations (Kim et al, 2005). Increased complication rates, including granuloma formation and the need for surgical intervention, also appear to be more closely linked to intracanalicular plug designs.

Pyogenic granulomas are not the only potential complication associated with punctal plug use. Proximal migration within the lacrimal drainage system can result in blockage, infection, and even plug erosion through lacrimal tissue (Mazow et al, 2007).

Conclusion

Because punctal plugs are commonplace and simple to use, it’s easy to forget that they require appropriate pre-surgical patient consultation and careful follow up, as the potential for complications requiring surgical intervention exists. In our Dry Eye Service, we discuss this with our patients. We also require them to sign a surgical consent form before the procedure. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #219.

Dr. Gaume Giannoni is a clinical associate professor at the University of Houston College of Optometry and is the director of the Dry Eye Center at the University Eye Institute. She also sees patients in a private practice setting and has received authorship honoraria from Bausch + Lomb.