Preservative-containing hypotensive drops as a potential trigger for epibulbar Rosai-Dorfman disease: A rare case report

PurposeTo report a rare case of bilateral conjunctival and epibulbar extranodal Rosai-Dorfman disease (RDD) without lymph node involvement, potentially associated with long-term use of benzalkonium chloride (BAK)-containing glaucoma medications.Case PresentationA 68-year-old male with a 10-year history of primary open-angle glaucoma, managed with multiple topical hypotensive agents, developed bilateral conjunctival and epibulbar nodules following chronic recurrent episodes of conjunctival inflammation over those 10 years. Histopathological examination and immunohistochemical staining confirmed the diagnosis of RDD, characterized by histiocytic proliferation with prominent emperipolesis. The patient underwent surgical excision of the lesions with homoconjunctival grafting. Postoperatively, his glaucoma regimen was modified to a preservative-free (BAK-free) topical therapy, and selective laser trabeculoplasty was performed to reduce the need for additional topical therapy. Comprehensive systemic evaluation revealed no lymphadenopathy or other extranodal organ involvement. At one-year follow-up, there was no evidence of recurrence, conjunctival inflammation had markedly subsided, and the glaucoma remained stable.ConclusionsThis case highlights a potential association between chronic conjunctival inflammation induced by BAK-containing glaucoma medications and the de novo emergence of epibulbar RDD. Although RDD remains a rare and poorly understood histiocytic disorder, our findings suggest that sustained ocular surface inflammation may act as a trigger in its pathogenesis. To our knowledge, this is the first reported case of ocular RDD potentially linked to long-term exposure to topical hypotensive therapy. Further studies are warranted to investigate the role of chronic inflammatory stimuli in the development of extranodal RDD, particularly within ocular tissues.