Treatment of a lacrimal pneumocele with punctal plug insertion

A 37-year-old man presented with symptoms of air and mucus reflux from the right medial canthus on blowing his nose. Examination showed crepitus in the region overlying the right lacrimal sac, and he was able to produce bubbles in his conjunctival lake on instillation of topical 2% fluorescein. Dacryoscintigraphy showed symmetrical slow passage of tracer from the lacrimal sac in the nasolacrimal duct indicating delay at the postsac level. Dacryocystography showed that the right lacrimal system contained round filling defects, suggesting the presence of soft tissue tumors. However, a CT scan showed an enlarged right lacrimal fossa with air in the nasolacrimal duct and no evidence of a mass. Following lower punctal plug occlusive canaliculoplasty on the right, using a preloaded silicone plug, the patient noted an immediate resolution of reflux symptoms.