English

Abstract

CASE SUMMARY: A 45year old lady presented to outpatient clinic with pain & swelling in the medial canthal area and watering from Left eye simulating acute dacryocystitis. Patient was treated for the same but with no response. After 4-5visits, she developed non healing ulcer over the same area. The patient was otherwise healthy, with no history of excessive sun exposure or any predisposing factors for skin cancer. Examination revealing 2cm×2cm ulcer with slightly elevated pigmented margin (fig: 1) involving the puncta posed a real diagnostic dilemma. The lesion was subjected for excisional biopsy with 3mm clear margin under local anaesthesia. As the punta were also involved, a medial 25% of full thickness lid was excised along with main lesion (Fig: 2). Concomitant dacryocystectomy was carried out. Canthal reconstruction was done followed by direct approximation of lid defects to newly formed canthus. A myo cutaneous glabellar flap was transposed to the defect area with inverted V-Y closure (fig: 3). Histopathological examination under low power showed solid islands of tumor cells with peripheral palisading; there is also a clefting artifact in between the stroma and epithelium. High power shows pigments within solid highland basal cells and in macrophages suggestive of pigmented basal cell carcinoma. 1month Postoperative period was uneventful, with acceptable cosmetic appearance. Unusual presentation of pigmented chronic ulcer with watering in a middle aged lady diverted our attention towards non-malignant pathology resulting in erroneous initial diagnosis & treatment.