Ligneous conjunctivitis presenting after strabismus surgery in the eighth decade of life

We present an atypical case of a 71-year-old male with recurrent ligneous conjunctivitis following bilateral rectus muscle recession for strabismus. Ligneous conjunctivitis is a rare, chronic form of pseudomembranous conjunctivitis most often seen in infants and children. The condition is typically caused by autosomal recessive variants in the PLG gene leading to plasminogen deficiency, resulting in recurrent fibrin-rich lesions on the conjunctiva due to impaired fibrinolysis. Histopathology revealed fibrin-rich material consistent with ligneous conjunctivitis. Serum plasminogen activity and antigen levels were markedly reduced. Whole exome sequencing (WES) identified compound heterozygous variants in the PLG gene, confirming plasminogen deficiency. Initial surgical excision resulted in lesion recurrence; however, treatment with subconjunctival fresh frozen plasma (FFP) injections and topical FFP eye drops led to sustained lesion resolution. This case highlights the late onset of ligneous conjunctivitis in an older adult, likely triggered by surgical trauma. It underscores the importance of considering plasminogen deficiency in recurrent conjunctival lesions, even in older patients.