Our patient presents with progressive ulcerative blepharitis and associated ocular surface disease that was nonresponsive to conservative and higher level therapies. The differential for this presentation is broad and includes infection (bacterial, viral, fungal, Demodex), carcinoma (squamous, basal, and sebaceous), autoimmune (sarcoid, lupus), rosacea, allergic and seborrheic dermatitis, erythema multiforme, and ichthyosis.
Given the extensive ocular treatments, we thought it would be prudent to take a step back and look at the disease presentation with a new set of eyes.
We stopped all topical eye medications and lid hygiene as well as obtained a smear/culture for viral, fungal, and bacterial infections. There was no Demodex noted on evaluation of epilated lashes. Viral and fungal studies were negative while both eyelids grew coagulase-negative mannitol-negative staphylococci and coagulase-negative mannitol-positive staphylococci and diphtheroids. Based on bacterial sensitivities, bacitracin ointment was restarted and Avenova (NovaBay Pharmaceuticals) was initiated as an adjuvant for a daily gentle lid hygiene routine. Despite escalating therapies with HydroEye (ScienceBased Health), doxycycline, and a Medrol DosePak (Pfizer Inc.), the ulcerations continued to worsen.
Basic laboratory evaluation and clinical presentation did not necessitate an autoimmune work-up. Ultimately, an eyelid biopsy was pursued and revealed extensive necrotizing granulomatous dermatitis and no evidence of carcinoma. After multiple extensive discussions, the patient remembered she had a cosmetic eyeliner tattoo procedure performed 10 years ago (Figure 2).