PUBLICATION EXCLUSIVE: Man presents with rapidly growing eyelid lesion

A 52-year-old Latin-American man was referred to the Oculoplastics service at the New England Eye Center for evaluation of presumed pyogenic granuloma. The patient reported a history of a rapidly growing “stye” in his left lower eyelid for the prior 2 weeks. He denied any associated pain, erythema or discharge. Medical history was positive only for diet-controlled diabetes. He denied any history of malignancy or sexually transmitted infections such as HIV. Ocular history was unremarkable, including any history of trauma or surgery to the eyelid. He was not taking any medications. The patient also denied any history of smoking, intravenous drug use or high-risk sexual activity. He worked as a driver.

Examination

Best corrected visual acuity was 20/25 in both eyes. The pupils were briskly reactive to light with no relative afferent pupillary defect in either eye, and IOP was 15 mm Hg in each eye. Extraocular muscle movements were fully intact, and confrontational visual fields were full in both eyes.

Figure 1. Photograph of external exam showing a raised left inferior eyelid with intact overlying skin that is mildly erythematous (a). Photograph of left lower eyelid upon eversion reveals an elevated growth on the medial palpebral conjunctiva that extends laterally and causes traction on the bulbar conjunctiva (b). Inferotemporal cystic-appearing bulbar conjunctival elevations are also noted.

External examination of the eyelids revealed a non-tender, elevated left lower eyelid with mild erythema but no ulceration (Figure 1a). Marginal reflex distance-2 was found to be 4 mm in the left eye compared with 6 mm in the right eye, indicating a relatively narrow left vertical interpalpebral fissure. Upon eversion of the left lower eyelid, a 7 mm × 9 mm raised, irregular, mildly vascularized conjunctival lesion was noted, measuring approximately 17 mm horizontally in its deeper tarsal portion (Figure 1b). Irregularities in palpation of the orbital fat suggested extension of the lesion into the orbit with no gross proptosis. There was a symblepharon as well as cystic-appearing elevated lesions on the inferotemporal bulbar conjunctiva. External examination was negative for any palpable lymph nodes.

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Click here to read the full publication exclusive, Grand Rounds at the New England Eye Center, published in Ocular Surgery News U.S. Edition, December 10, 2016.