A 68-year-old-man was seen in consultation for a suspicious medial canthal lesion that developed over a 2-year period. The raised, nodular lesion was skin colored, had a raised pearly border and a central depression with superficial crusting. Basal cell carcinoma was suspected and an excisional biopsy was performed. However, a granulomatous inflammatory process with features consistent with gout was identified. Further inquiry confirmed a history of gout including prior tophi on each elbow. Gouty tophi are extremely rare in the periocular area but should be considered in the differential diagnosis of basal cell carcinoma as they may have a similar clinical appearance.