Orbit, 2014; 33(2): 156–158 ! Informa Healthcare USA, Inc. ISSN: 0167-6830 print / 1744-5108 online DOI: 10.3109/01676830.2013.853808


Free-floating Pyogenic Granuloma of the Lacrimal Sac Abbas Bagheri1, Nasrin Rafati1, Reza Erfanian Salim2, and Shahin Yazdani1 1

Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran and 2Noor Eye Hospital Research Center, Tehran, Iran

ABSTRACT The authors report a 13-month-old girl with chronic dacryocystitis, and history of three times probing and once inferior turbinate infracture. She underwent dacryocystorhinostomy due to failure of previous procedures. During surgery a free floating reddish mass was extracted from the lacrimal sac. Histopathologic examination revealed the mass to be a pyogenic granuloma. Keywords: Lacrimal sac, lacrimal surgery, pyogenic granuloma


resulted in a purulent reflux but no blood regurgitated. We requested a high resolution orbital CT scan and found a soft tissue mass in the right lacrimal sac (Figure 2) and therefore suggested reoperation. At the age of 13 months we performed conventional external dacryocystorhinostomy (DCR); when the lacrimal sac was opened, we encountered a dark red, cherry-like free-floating mass in the sac (Figure 3). The size of the mass was 10  6  5 mm, compressing the sac mucosa internally and the lacrimal sac had large crypts. After removal of the mass, the operation was continued and completed with silicone intubation. Microscopic evaluation of the mass showed a lobulated hypervascular tissue including numerous capillaries and a loose edematous stroma consistent with a diagnosis of pyogenic granuloma (Figure 4). Clinical signs and symptoms resolved completely after the operation with a barely visible scar (Figure 1B) and after 5 years of follow-up, no recurrence was encountered.

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Pyogenic granuloma is the result of an arrest in scar formation in wounds of the skin and mucosa, and is frequently seen following traumatic or surgical insults on epithelial areas.1 These lesions present as pedunculated or sessile red masses.1 Ponceat, in 1897, first described these lesions as botryomycosis.2 Histopathologically these masses are composed of numerous capillaries within a loose stroma.1 The lesion is not inflammatory and not truely pyogenic or granulomatous.1 The condition occurs in both sexes and its frequency decreases with older age;1 it has rarely been reported in the lacrimal sac.3–5 The authors herein report a case of free floating pyogenic granuloma of the lacrimal sac.

CASE REPORT A 10-month-old girl was referred for epiphora with purulent discharge in her right eye from birth and an enlarged lacrimal sac from the age of 4 months. She had a history of 3 previous unsuccessful probings of the nasolacrimal duct, with infracture of the inferior turbinate on one occasion. On external examination, the right lacrimal sac was red and enlarged (Figure 1A). Sac compression

COMMENT Chronic dacryocystitis is a chronic infection of the lacrimal sac which may be associated with obstructive symptoms and the sac becomes enlarged.6

Received 7 May 2013; Revised 28 September 2013; Accepted 7 October 2013; Published online 11 November 2013 Correspondence: Abbas Bagheri MD, Ophthalmic Research Center, Labbafinejad Medical Center, Boostan 9 St. Pasdaran Avenue, Tehran 16666, Iran. E-mail: [email protected]


Lacrimal Sac Pyogenic Granulomas


FIGURE 1. The patient’s appearance before (A) and after surgery (B). Note lacrimal sac enlargement before surgery and a faint scar after surgery.

FIGURE 2. Coronal orbital CT scan shows a large mass in the right lacrimal sac.

FIGURE 4. Histologic section of the mass shows edematous and hypervascular stroma consistent with pyogenic granoluma (H&E Stain 40).

FIGURE 3. Gross appearance of the mass after its removal.

Pyogenic granuloma may originate from the mucosa of ocular adnexa1; when present in the lacrimal drainage system, it can cause obstruction and present with bloody epiphora secondary to !

2014 Informa Healthcare USA, Inc.

fragility of the abnormal tissue.7 Pyogenic granuloma of the lacrimal sac may be primary or develop secondary to inflammation, trauma, surgery or foreign bodies such as silicone tubes.1 Ocular pyogenic granuloma usually originate from the conjunctiva and in a study on 100 cases of ocular and adnexal pyogenic granulomas, no case of lacrimal sac lesions was reported.8 The frequency of pyogenic granulomas based on histopathologic reports of lacrimal sac specimens has been up to 0.3%.9–11 Since sac enlargement and purulent discharge in the current case had developed after probing, it may be concluded that the pyogenic granuloma was secondary to previous traumatic surgeries. The first choice of treatment in congenital nasolacrimal duct obstruction is simple probing which can be repeated with significant success rates12 and can be

158 A. Bagheri et al. combined with inferior turbinate infracture.13 The next step is silicone intubation or DCR especially when chronic dacryocystitis is present.1,14 Our case improved with the last procedure. In summary when simple probing fails in a child, especially when history of trauma, surgery, sac enlargement and bloody discharge is present, or in the context of acute or chronic dacryocystitis, one should consider pyogenic granuloma of the lacrimal sac in the differential diagnosis.

DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

REFERENCES 1. Yazici B, AyseTo¨r A, Aker S. Pyogenic granuloma of the lacrimal sac. Int Opthalmol 2009;29:57–60. 2. Poncet A, Dor L. Botryomycosehumain. Rev Chir 1897;18: 996–1000. 3. Haritoglu C, Hoops JP. Pyogenes granulom des tranesackes bei chronischer dakryozystitis. [pyogenic granuloma of the lacrimal sac]. Klin Monatsbl Aug enheikd 2002; 219:373–375. 4. Heathcote JG, Allen LH, Willis NR. Plasma cell granuloma of the lacrimal sac. Can J Ophthalmol 1987;22:387–390.

5. Asiyo MN, Stefani FH. Pyogenic granulomas of the lacrimal sac. Eye 1992;6:97–101. 6. Deok Choi J, Hyeok Lee J, Jung Paik H. A silastic sheet found during endoscopic transnasal dacryocystorhinostomy for acute dacryocystitis. Kor J Ophthalmol 2006;20: 65–69. 7. Mills SE, Cooper PH, Fechner RE. Lobular capillary hemangioma: the underlying lesion of pyogenic granuloma- a study of 73 cases from the oral and nasal mucous membranes. Am J Surg Pathol 1980;4:470–479. 8. Ferry AP. Pyogenic granuloma of the eye and ocular adnexa: a study of 100 cases. Trans Am Ophthalmol Soc 1989; 87:327–347. 9. Anderson NG, Wojno TH, Grossniklaus HE. Clinicopathologic findings from lacrimal sac biopsy specimens obtained during dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2003;19:173–176. 10. Lee-Wing MW, Ashenhurst ME. Clinicopathologic analysis of 166 patients with primary acquired nasolacrimal duct obstruction. Ophthalmology 2001; 108:2038–2040. 11. Tucker N, Chow D, Stockl F, et al. clinically suspected primary acquired nasolacrimal duct obstruction: clinicopathologic review of 150 patients. Ophthalmology 1997;104: 1882–1888. 12. Nerad JA. Diagnosis and management of the patient with tearing. In: Techniques in Ophthalmic Plastic Surgery, 1st ed. Nerad JA, ed. Philadelphia: WB Saunders, 2010: 261–297. 13. Putterman AM. Basic oculoplastic surgery. In: Principles and Practice of Ophthalmology, 3rd ed. Peyman GA, Sanders DR, Goldberg MF, eds. Philadelphia: WB Saunders, 1980:2277–2279. 14. Migliori ME, Putterman AM. Silicone intubation for the treatment of congenital lacrimal duct obstruction: successful results removing the tubes after six weeks. Ophthalmology 1988;95:792–795.


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Free-floating pyogenic granuloma of the lacrimal sac.

The authors report a 13-month-old girl with chronic dacryocystitis, and history of three times probing and once inferior turbinate infracture. She und...
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