How is a lump on the eye diagnosed and treated?

Diagnosis and Management of a Lump on the Eye

A visible lump or nodular lesion on the eye requires immediate slit-lamp biomicroscopy examination by an ophthalmologist to determine its location (conjunctival, corneal, or intraocular), depth of involvement, and whether it represents a benign condition like Salzmann nodular degeneration or a potentially malignant process requiring biopsy. 1, 2

Immediate Assessment Required

Critical red flags necessitating urgent ophthalmology referral within 24 hours include: 3, 4

• Vision changes or blurred vision 3, 4
• Severe photophobia 3, 4
• Moderate to severe eye pain 3, 4
• Mid-dilated or poorly reactive pupil 3
• Intense conjunctival injection surrounding the lesion (suggests possible metastatic disease or malignancy) 2
• History of systemic cancer (raises concern for conjunctival metastasis) 2

Diagnostic Evaluation

Essential Examination Components

The ophthalmologist must perform: 3, 2

• Visual acuity testing as baseline 3
• Pupil examination for reactivity and afferent defects 3
• Slit-lamp biomicroscopy to evaluate the lesion's location (bulbar conjunctiva, limbus by clock hour, cornea), depth, elevation, vascular characteristics, and color 1, 2
• Fluorescein staining to assess corneal integrity 3
• Intraocular pressure measurement 3

Location-Specific Considerations

Peripheral corneal lesions (e.g., Salzmann nodular degeneration) may be asymptomatic but can cause central irregularity and visually significant astigmatism. 1

Conjunctival masses appearing as solitary, yellowish lesions with intense injection should raise suspicion for metastatic disease, especially in patients with cancer history. 2 A common pitfall is misdiagnosing sebaceous carcinoma or metastatic disease as chronic blepharoconjunctivitis, which delays appropriate treatment. 2

Differential Diagnosis Framework

Benign Conditions

• Salzmann nodular degeneration: Peripheral corneal nodules that may be subtle and asymptomatic 1
• Corneal edema with opacification: Can present with blurred vision, photophobia, and foreign-body sensation 1

Malignant or Pre-Malignant Lesions

• Conjunctival squamous cell carcinoma: Requires assessment for invasion into episclera or corneal stroma, margin status, and degree of differentiation 1, 2
• Conjunctival melanoma: Needs evaluation for depth of invasion and margin involvement 1
• Sebaceous carcinoma: May present with yellowish appearance mimicking other conditions 2
• Metastatic disease: Presents as yellowish mass with intense injection and possible mucopurulent discharge 2

Biopsy Indications and Technique

Excisional or incisional biopsy is indicated when: 1

• Malignancy is suspected based on appearance
• The lesion shows progressive growth
• There is uncertainty about diagnosis after clinical examination

Proper biopsy technique requires: 1

• Documentation of exact anatomic location (by quadrant for bulbar conjunctiva, by clock hour for limbus) 1
• Measurement of lesion dimensions (length, width, thickness) 1
• Assessment of minimum distance between lesion edge and surgical margin 1
• Description of ulceration presence, color, and attached tissue (episclera, cornea) 1

Treatment Algorithm

For Lesions WITHOUT Red Flags:

• Routine ophthalmology referral within 4 weeks for definitive diagnosis and management planning 4
• Avoid empiric treatment before establishing diagnosis 3, 4

For Lesions WITH Red Flags:

• Emergency ophthalmology referral within 24 hours 4
• Do not initiate treatment before ophthalmology evaluation, as empiric topical steroids may worsen infectious processes or mask underlying malignancy 4

Surgical Management Considerations:

For confirmed benign peripheral corneal opacification, treatment is indicated when associated with functional visual loss or discomfort. 1 Chronic epithelial breakdown may necessitate intervention to stabilize the ocular surface and prevent complications. 1

For malignant lesions, surgical excision with adequate margins is required, with histopathologic confirmation of margin status, invasion depth, and differentiation grade. 1

Critical Pitfalls to Avoid

• Never dismiss a conjunctival mass as benign inflammation without slit-lamp examination and consideration of biopsy, especially with yellowish appearance and intense injection 2
• Do not delay biopsy in lesions with atypical features or those unresponsive to conservative management 1
• Avoid treating presumed "chronic conjunctivitis" without ruling out sebaceous carcinoma or metastatic disease 2
• Never initiate corticosteroids empirically before establishing diagnosis in patients with ocular masses 4