A 57-year-old Hispanic male was followed by the Wills Eye Institute Cornea Service for six weeks following excision of a recurrent nasal pterygium with mitomycin and a superior conjunctival autograft. Although the area of pterygium excision was healing well, a multinodular area of elevation of the inferior and lateral conjunctiva had developed, extending into the inferior cul-de-sac. Treatment with oral cephalexin and topical neomycin/polymyxin B/dexamethasone was immediately initiated, but this did not ameliorate the patient’s conjunctival findings or associated symptoms of mild eye discomfort and foreign body sensation. After five weeks of presumptive therapy, the patient admitted that he never filled his prescription for cephalexin and had discontinued topical treatment a few weeks earlier. He subsequently was referred to the Oculoplastic and Orbital Surgery Service eleven weeks postoperatively for further management. The patient denied pain, diplopia or changes in visual acuity.
The patient’s past ocular history was significant for recurrent pterygium following initial excision in both eyes 30 years previously and twice more in the left eye. His past medical history was significant for coronary artery disease, hypertension, hyperlipidemia, type 2 diabetes (well controlled), gastroesophageal reflux and asthma. His medications included clopidogrel, aspirin, multiple anti-hypertensives, a beta blocker, insulin, two oral hypoglycemics, albuterol and a proton pump inhibitor. He denied any recent travel and had no pets at home. Social history was negative for high-risk sexual activity or alcohol, tobacco and recreational drug use.
The patient’s uncorrected visual acuity was 20/50 in the right eye and 20/60 in the left. Pupils were normal with no afferent pupillary defect. Motility was full on the right and diminished approximately 20 percent in all ductions except adduction on the left. He denied diplopia in all directions of gaze. Intraocular pressure was within normal range and equal in both eyes. There was no proptosis. No preauricular lymphadenopathy was appreciated. The patient had an isolated, non-tender, raised, erythematous nodule on his left lower lid. The anterior exam of his left eye was significant for marked conjunctival injection with nodularity extending inferotemporally (See Figure 1). The surgical site (nasal conjunctiva) appeared benign and there was no corneal staining or infiltrate. Nuclear sclerotic lens changes were present. His funduscopic exam was normal in both eyes.
What is your differential diagnosis? What further workup would you pursue?