Arch Soc Esp Oftalmol 2007 Oct;82(10):653-6.
CASE REPORT: We report the case of a 65-year-old woman with dry eye syndrome who was referred because of a red mass in the internal left canthus. Three years previously two Smart Plugs had been introduced into both lacrimal punctums of that eye. We diagnosed a pyogenic granuloma and removed it. Two weeks later a new granuloma developed so both the granuloma and the punctal plug were removed. The patient became asymptomatic following this latter procedure. DISCUSSION: A pyogenic granuloma in a Smart Plug punctum is described. This rare complication is generally associated with the use of silicone punctal plugs, being possibly caused by the chronic irritation of the accumulated detritus and necessitating removal of the plug.
I always get irritated when I read about somebody getting two durable plugs placed in the same punctum. If there's no reliable way to figure out whether the first one is still there, is it ever safe to shove another one in?