Lichen sclerosus (LS) is a complex chronic inflammatory disease that commonly presents in women in their fifth or sixth decades. The disease commonly involves the anogenital region of males and females, but approximately 15% of LS patients present with extragenital lesions of the neck, shoulders, trunk, wrists, oral mucosa, and legs [3]. One rare manifestation of LS is the involvement of the eyelids which has been reported in ten cases. All reported cases were treated with either corticosteroids or tacrolimus, with outcomes ranging from no improvement to complete resolution.

This report is the first case of a patient with extra-palpebral LS undergoing a LASIK procedure. The patient presented with a hypopigmented lesion of the left lower eyelid. Like previous presentations, the patient's extra-palpebral LS had no clinical symptoms involving the eye and presented with no complications in surgery and had an excellent outcome three months post-op.

When assessing patients’ candidacy for ocular surgery (i.e., LASIK, PRK or Cataract surgery), it is imperative to identify possible contraindications or risk factors. It is important to note that in the ten reported cases of extra-palpebral LS, none of the presentations manifested with histological changes involving the conjunctiva, cornea, retina, or chambers of the eye. Although one patient presented with LS-induced keratoconjunctivitis sicca, severe cases of dry eye are only a relative contraindication for surgeries such as LASIK, PRK, or Cataract surgery. An evaluation for adequate tear production via the Schirmer tear test may be necessary for patients with eyelid-associated LS and a history of dry eye [13-15]. Management of dry eye should be undertaken even prior to corneal refractive surgery. Additionally, LS is associated with an increased risk of developing Squamous Cell Carcinoma (SCC). While there has only been one case of extragenital LS associated with SCC manifestation, none of the presentations reported transformation to SCC of the eyelid [16].

Differentiating extra-palpebral LS from other similarly presenting pathologies is critical in reducing ocular surgery morbidities. No ocular manifestations of LS have been reported to date;

However, many other pathologies presenting with a hypopigmented eyelid lesion may cause ocular complications. The differential diagnosis for hypopigmented lesions of the eyelid includes leprosy, morphea, sarcoidosis, systemic scleroderma, vitiligo, tinea versicolor, and lichen planus [4,10,17-19].  Some autoimmune diseases such as sarcoidosis are associated with impaired immune functions and are at greater risk for infection, dry eye, and other adverse side effects associated with ocular surgery [18]. Others, such as morphea (localized scleroderma), can have significant ocular involvement and cause anterior segment inflammation and anterior uveitis [20]. Patients with lichen planus can result in complications ranging from conjunctival scarring to blepharitis [19].

Utilizing a multidisciplinary approach including specialists in internal medicine, dermatology, and pathology is advised to appropriately diagnose unknown lesions and assess any risk factors that may affect ocular surgery outcomes.