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Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 717-719

Anterior segment optical coherence tomography features of peripunctal nevus

1 Department of Orbit and Oculoplasty, Sadguru Netra Chikitsalya, Chitrakoot, Madhya Pradesh, India
2 Department of Pathology, Central Diagnostic Centre, Indore, Madhya Pradesh, India

Date of Submission17-Feb-2021
Date of Acceptance25-Mar-2021
Date of Web Publication09-Oct-2021

Correspondence Address:
Dr. Gaurav Garg
Department of Orbit and Oculoplasty, Sadguru Netra Chikitsalaya, Chitrakoot, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_401_21

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Peripunctal tumors usually account for as low as 6.3% of all punctal lesions. Peripunctal nevus is benign in nature, but it can cause epiphora by its sheer mass effect or cosmetic blemish. Anterior segment optical coherence tomography has recently been used in various lower punctal pathologies. A 60-year-old lady presented with a painless, benign peripunctal nevus and underwent excision biopsy. Anterior segment optical coherence tomography was used for its in vivo assessment and defining features of the lesion. It showed a hyperreflective epithelial thickening and gradient hyporeflective layers with punctal occlusion.

Keywords: Anterior segment optical coherence tomography of lower punctum, anterior segment optical coherence tomography of peripuntal nevus, lower punctum pathology, peripunctal nevus, peripunctal tumors

How to cite this article:
Garg G, Patidar N, Gupta R. Anterior segment optical coherence tomography features of peripunctal nevus. Indian J Ophthalmol Case Rep 2021;1:717-9

How to cite this URL:
Garg G, Patidar N, Gupta R. Anterior segment optical coherence tomography features of peripunctal nevus. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2022 May 24];1:717-9. Available from: https://www.ijoreports.in/text.asp?2021/1/4/717/327743

Peripunctal tumors are rare entities. Various lesions have been reported: pigmented moles, epithelial invasive cyst, nonpigment complex moles, papillomastoma, acidophilic adenomas, and intradermal nevus, which usually present as either circular or dome-shaped swelling surrounding the punctum.[1],[2] These lesions may occlude the punctum by their sheer size or invade the punctum in a few, which may lead to epiphora. Because of the tear film distortion, they can also cause foreign body sensation. Some patients present due to cosmetic unacceptance.[3] Melanocytic nevi have a predilection for bulbar conjunctiva and rarely present involving caruncle, fornix, plica semilunaris, cornea, or peripunctum.[4],[5]

Anterior segment optical coherence tomography has been reported to describe healthy puncta and punctum pathologies.[6],[7] Currently, there is no literature on anterior segment optical coherence tomography features of peripunctal nevus. The present case report is unique because it is the first attempt by the authors to report the features of peripunctal nevus occluding the punctum on anterior segment optical coherence tomography.

This report adhered to the ethical principles outlined in the Declaration of Helsinki as amended in 2013.

  Case Report Top

A 60-year-old Asian Indian lady presented to us with a gradually progressive pigmented mass in the right eye for the past 5 years. There was no association with pain or trauma. There was no history of change in color, postural variation in size, bleeding from mass, or significant watering. On examination, the bilateral vision was 20/20 with the normal anterior and posterior examination. On lesion examination in the right eye, there was a pigmented black, elevated, noncompressible mass around the lower lid punctum with a size of 5 × 5 × 3 mm [Figure 1]a. The lesion was well-defined, nonmobile, with normal vascularity on the palpebral side at the base only. Punctum was presented as central pitting in the lesion. There was no fixity or adhesion to the surrounding tissues. Fluorescein dye disappearance test was positive. Syringing or probing from the lower punctum was avoided as it might rupture the lesion or might form a false tract of the canaliculus. But the nasolacrimal duct was found patent when syringing was done via upper punctum, suggestive of lower proximal block or mechanical compression of the punctum.
Figure 1: (a) Clinical image showing the lower lid peripunctal nevus of the right eye with variable pigmentation, vascularity at the base, and central pitting representing punctum. (b) Histopathological image: Low magnification view showing punctum (asterisk) with epidermal–dermal junction and dermis showing dense brown-colored melanin pigment. (c) Anterior segment optical coherence tomography of peripunctal nevus

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Anterior segment optical coherence tomography was performed using 1,310 nm wavelength, an axial resolution of 18 μm, and a transverse resolution of 60 μm. To focus on the lesion, the lower eyelid was everted gently using a cotton applicator just under the lower punctum taking care of not causing any undesired occlusion or compression of the lesion and punctum. To align the lesion and the punctum with the axis of the scanner's infrared beam, it was everted perpendicularly to the light source. The scan was captured along the mucocutaneous junction involving the lesion horizontally. On scanning, a hyperreflective outer layer corresponding to the epithelial thickening of length 0.35 mm and a gradient hyporeflective inner layers of the lesion, noted up to 1.65 mm with central punctum, was seen as a conical hyporeflective area (diameter of 0.28 mm and vertical length of 0.13 mm) with obstruction at the distal end of vertical canaliculus due to mass effect [Figure 1]c. This hyperreflective layer of the lesion on anterior segment optical coherence tomography represents the dense cluster of melanocytes, which was confirmed on histopathology.[8] But the hyporeflective layer is due to the cystic component of the lesion.

The patient presented to us for aesthetic purpose and underwent excision biopsy and canaliculotomy. Postoperatively, the patient was given antibiotic steroid eye drops. On histopathology, gross examination showed a black, soft tissue mass measuring 3 × 2 mm. Microscopic examination revealed thinned epidermis with punctum underlying the epidermal–dermal junction, and the dermis showed a vaguely circumscribed lesion of nevus cells arranged in a nest with cords and clusters. Nevus cells are uniform cells with a thin rim of cytoplasm and bland nuclei. Cytoplasm shows a variable amount of melanin pigment. Superficial clusters show more pigmentation, and cells deeper in the lesion have smaller nuclei and decreased pigmentation. There was no evidence of ulceration, increased mitotic activity, or atypia; suggestive of junctional melanocytic nevus of the peripunctal region [Figure 1]b.

  Discussion Top

The incidence of peripunctal tumors is as low as 6.3% of all punctal lesions, and it constitutes merely 0.27% of all oculoplastic surgeries.[5] These lesions usually present as a dome-shaped peripunctal swelling of the lower lid causing slit-like puncta. The patients usually present with complaints of epiphora because of invaded or displaced puncta or cosmetic reasons. This lesion can be surgically excised with or without a punctal stent.

Anterior segment optical coherence tomography is a noncontact modality that uses an infrared 1,300 nm wavelength superluminescent diode. Wawrzynski et al.[7] were the first to prove its feasibility for the assessment of lower punctum. Since then there have been various publications involving anterior segment optical coherence tomography features of healthy punctum and its pathologies.[6],[9],[10] To the best of our knowledge, this is the first attempt to capture anterior segment optical coherence tomography and defining features of lower lid peripunctal melanocytic nevus.

  Conclusion Top

Although the gold standard for diagnosis and staging of eyelid lesions remains as biopsy with histopathology, in the future, further studies may provide intriguing insights on anterior segment optical coherence tomography features of various peripunctal tumors, both benign and malignant, and their comparison with histopathological features.


The authors wish to thank Mr. Satyendra Dubey; B.Opt, Department of Glaucoma, Sadguru Netra Chikitsalya, Chitrakoot, India.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rumelt S, Pe'er J, Rubin PAD. The clinicopathological spectrum of benign peripunctal tumours. Graefes Arch Clin Exp Ophthalmol 2005;243:113-9.  Back to cited text no. 1
Yonekawa Y, Jakobiec FA, Zakka FR, Kim N. Keratinizing cyst of the lacrimal punctum. Cornea 2013;32:883-5.  Back to cited text no. 2
Zhu C, Zheng X, Qiao H, Da Z, Zhou H, Wang T. Surgical treatment of a case of upper peripunctal intradermal nevus of the upper eye lid. Int J Clin Exp Med 2020;13:1028-32.  Back to cited text no. 3
Novais GA, Fernandes BF, Belfort RN, Castiglione E, Cheema DP, Burnier MN. Incidence of melanocytic lesions of the conjunctiva in a review of 10 675 ophthalmic specimens. Int J Surg Pathol 2010;18:60-3.  Back to cited text no. 4
Hwang CS, Lee S, Yen MT. Peripunctal melanocytic nevus. Int Ophthalmol 2011;31:497-9.  Back to cited text no. 5
Timlin HM, Keane PA, Day AC, Salam T, Abdullah M, Rose GE, et al. Characterizing the lacrimal punctal region using anterior segment optical coherence tomography. Acta Ophthalmol 2016;94:154-9.  Back to cited text no. 6
Wawrzynski JR, Smith J, Sharma A, Saleh GM. Optical coherence tomography imaging of the proximal lacrimal system. Orbit 2014;33:428-32.  Back to cited text no. 7
Yiu G, Vuong VS, Oltjen S, Cunefare D, Farsiu S, Garzel L, et al. Effect of uveal melanocytes on choroidal morphology in rhesus macaques and humans on enhanced-depth imaging optical coherence tomography. Invest Ophthalmol Vis Sci 2016;57:5764-71.  Back to cited text no. 8
Allam RSHM, Ahmed RA. Evaluation of the Lower Punctum Parameters and Morphology Using Spectral Domain Anterior Segment Optical Coherence Tomography. J Ophthalmol 2015;2015. doi:https://doi.org/10.1155/2015/591845.  Back to cited text no. 9
Elshorbagy MS, Shalaby OE, Eldesouky MA, Awara AM. Anterior segment Optical coherence tomography (AS-OCT) guided reversal of edematous punctal occlusion. Clin Ophthalmol 2020;14:1467-72.  Back to cited text no. 10


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