What is the possible diagnosis for left eye pain, described as dull pain, with a small bump at the corner and a small ulcer on the inner lower eyelid, that worsens over time and has lasted for 3 weeks?

Possible Diagnosis: Chronic Anterior Blepharitis with Ulcerative Component, Consider Sebaceous Carcinoma

The most likely diagnosis is chronic anterior blepharitis with ulcerative features, but given the unilateral presentation, 3-week duration unresponsive to typical measures, presence of an ulcer on the inner lower eyelid, and the bump at the corner, sebaceous carcinoma must be ruled out immediately. 1

Primary Differential Diagnosis

Most Likely: Staphylococcal Blepharitis with Ulceration

• Staphylococcal blepharitis characteristically presents with scaling, crusting, erythema of the eyelid margin, and can progress to ulcerative blepharitis with chronic inflammation. 1
• The dull pain worsening in the morning that improves during the day is consistent with inflammatory eyelid disease, as overnight lid closure allows inflammatory mediators to accumulate. 1
• The "bump" at the corner could represent a chalazion or hordeolum, which are common complications of chronic blepharitis. 1
• The small ulcer on the inner lower eyelid is concerning for ulcerative blepharitis, where chronic inflammation leads to tissue breakdown. 1

Critical Red Flag: Sebaceous Carcinoma

Sebaceous carcinoma must be excluded in any patient with chronic, unilateral, unresponsive eyelid inflammation, especially with ulceration and focal findings. 1

• Key warning signs present in this case: 1

  • Unilateral presentation (left eye only)
  • Ulceration of the eyelid
  • Nodular mass/bump at the corner
  • 3-week duration without improvement
  • Worsening symptoms despite time

• Sebaceous carcinoma should be considered in patients with unresponsive, chronic, unilateral blepharitis or conjunctivitis, or recurrent chalazia in the same location. 1

• Additional concerning features to assess include: loss of normal eyelid margin anatomy, focal lash loss (ciliary madarosis), hard nodular non-mobile mass, and yellowish discoloration. 1

Immediate Clinical Assessment Required

Examination Priorities

Perform detailed slit-lamp biomicroscopy focusing on: 1

• Eyelid margin characteristics: ulceration extent, loss of normal architecture, vascularization, hyperemia 1
• The ulcer itself: size, depth, borders (irregular borders suggest malignancy), any yellowish nodules 1
• Lash assessment: focal lash loss or misdirection at the site 1
• Palpation: whether the bump is mobile or fixed (fixed suggests malignancy) 1
• Asymmetry: compare carefully to the right eye 1
• Conjunctival examination: look for pagetoid spread (yellow conjunctival nodules with intense inflammation) 1

Management Algorithm

If ANY of the following are present, biopsy is mandatory: 1

• Marked asymmetry between eyes
• Fixed, hard nodular mass
• Focal lash loss at the lesion site
• Ulceration with irregular borders
• Yellowish discoloration or conjunctival nodules
• Resistance to standard blepharitis therapy (already 3 weeks)

Before obtaining biopsy for suspected sebaceous carcinoma, consult with pathology regarding need for frozen sections and mapping of conjunctiva to search for pagetoid spread, as fresh tissue may be needed to detect lipids using special dyes like oil red-O. 1

If Malignancy is Excluded: Blepharitis Treatment

Initiate aggressive eyelid hygiene immediately: 1

• Warm compresses for 5-10 minutes twice daily to soften crusts and improve meibomian gland secretions 1
• Eyelid scrubs with diluted baby shampoo or commercial eyelid cleansers to remove debris and bacterial colonization 1

Topical antibiotic ointment for ulcerative component: 1

• Bacitracin or erythromycin ointment applied to eyelid margin twice daily for 2-4 weeks 1
• This addresses the Staphylococcus aureus colonization that drives ulcerative blepharitis 1

Consider short-term topical corticosteroid if severe inflammation: 1

• Low-potency steroid ointment for 1-2 weeks only 1
• Must measure intraocular pressure at baseline and follow-up within 2-3 weeks if corticosteroids prescribed 1

Critical Pitfalls to Avoid

The single most dangerous error is dismissing unilateral, chronic eyelid inflammation as simple blepharitis without considering malignancy. 1 Sebaceous carcinoma is notoriously difficult to diagnose and can masquerade as chronic blepharitis or recurrent chalazion for months. 1

Do not delay biopsy if the patient fails to improve with standard blepharitis therapy within 2-4 weeks or if any red flag features are present. 1

Basal cell carcinoma and squamous cell carcinoma are the most common malignant eyelid tumors, but sebaceous carcinoma is particularly aggressive with pagetoid spread and can induce severe conjunctival inflammation. 1

Follow-Up Timing

• If treating as blepharitis: re-evaluate in 1-2 weeks to assess response 1
• If no improvement or worsening: proceed immediately to biopsy 1
• If biopsy performed: urgent ophthalmology or oculoplastics referral for results and definitive management 1