Millet-Seed Tarsal Conjunctivitis in Eyelid Sarcoid

A 59-year-old female with known cardiac and pulmonary sarcoidosis was referred for progressive right upper eyelid ptosis and thickening after right dacryocystorhinostomy 2 years ago (panel A). The examination was significant for right upper eyelid ptosis, bulbar conjunctival injection, forniceal symblepharon, and nonvisible puncta. Eyelid eversion revealed diffuse conjunctival hyperemia and yellow “millet-seed”-like nodules (panel B). She underwent a right upper eyelid full-thickness biopsy owing to concerns for malignancy. Histopathology demonstrated chronic conjunctivitis with noncaseating granulomas consistent with sarcoid (panel C). A regimen of oral prednisone, mycophenolate mofetil, and dapsone resulted in improvement of tarsal conjunctivitis, nodularity, and ptosis (panel D). The most common ocular manifestation of sarcoidosis is uveitis (30%–70%). Conjunctival involvement is also common (40%) and usually manifests as conjunctival nodules comprised of noncaseating granulomas. It is important for ophthalmologists to be aware of the ocular manifestations of sarcoidosis as they may be the first sign of systemic disease.