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--- conjunctival_pigmented_lesions [2025/09/29 22:45] – created Scott Larson
+++ conjunctival_pigmented_lesions [2026/02/25 19:50] (current) – Scott Larson
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 ====== Conjunctival Pigmented Lesions ======
-FIXME
+====Nevi====
+  * Usually appear in childhood
+  * Maybe pigmented or non-pigmented
+  * May become more pigmented with puberty or pregnancy
+  * Appearance
+    * well circumscribed
+    * cystic spaces
+    * Vascular supply
+  * Categorized histologically as
+    * Junctional
+    * Compound
+    * Subepithelial
+====Lesions arising from melanocytes====
+===Complexion Associated Melanosis (CAM)===
+  * Bilateral perilimbal pigmentation in darkly pigmented inviduals
+  * Doesn't progress to melanoma
+===Primary Acquired Melanosis (PAM)===
+  * Usually seen in fair skinned middle aged or older
+  * flat, unilateral, patchy, golden yellow or brown area, which may extend onto the cornea or corneal may similarly be involved.
+  * PAM with atypia can progress to melanoma
+  * PAM without atypia is low to no risk of transformation
+  * Treatement
+    * smaller lesions can be monitored, watching for nodularity, thickening, vascularity
+    * if changes or larger lesion, excision is recommended
+    * Excision
+      * Margins 4-5 mm
+      * Double freeze-thaw slow cryotherapy applied to the conjunctival edges
+    * For corneal PAM, apply absolute alcohol for one minute then epitheliectomy
+    * For diffuse disease or tarsal conjunctiva
+      * Cryotherapy with double freeze-thaw
+      * Topical interferon alpha-2b
+      * Topical mytomycin C 0.02% or 0.04%
+        * QID x 1 week
+        * Pause 1-2 weeks
+        * then QID x 1 week
+        * Repeat above until the pigment resolves, usually for 2-3 cycles
+        * punctual plugs placed before treatment
+        * use artificial tears and topical steroids for corneal toxicity
+===Malignant Melanoma===
+  * Patients are usually 60-70 years old
+  * Limbus most common but can appear in the caruncle, tarsus or fornix
+  * Raised mass with feeder vessels
+  * Treatment
+    * Avoid incisional biopsy to prevent tumor seeding
+    * Excision with dry no-touch technique with margins of 4-6 mm
+    * Cryotreatment to conjunctival edges with double freeze-thaw
+    * Absolute alcohol to corneal lesions with
+    * Sclerectomy may be needed for tumors adherent to the sclera applying cautery and cryotherapy to the base
+    * Closure with primary closure or amniotic graft to cover the defects
+    * Sentinel node biopsy should be considered for lesions larger than 2 mm or high risk features on histopathology
+  * Prognosis
+    * Local recurrence 45% at 5 years and 59% at 10 years
+    * Mortality: 5-17% at 5 years- 9-35% at 10 years
+    * Denovo lesions have worst prognosis
+    * Poorer survival: older age, male, non-white, tumors with nodularity or ulceration.
+====Summary Table====
+^ Type      ^ History                                                 ^ Color                                                   ^ Appearance                                                                        ^ Laterality                                            ^ Specific Features                                ^ Chance of Maligancy                ^ Primary Management                                                                        ^
+^ Nevus     | Onset in childhood                                      | Iight brown or non-pigmented                            | slightly raised and cystic with well defined margins                              | most unilateral and solitary                          | pigmentation changes with puberty and pregnancy  | rare                               | Photograph and observe every 6-12 months                                                  |
+^ CAM       | In darkly pigmented individuals, can increase with age  | Brown                                                   | flat, non-cystic, diffuse, will-defined margins, usually prominent around limbus  | bilateral                                             | can be extensive                                 | rare                               | Photograph and observe every 6-12 months                                                  |
+^ PAM       | Newly pigmented                                         | light to dark brown                                     | flat, diffuse and non-cirumscribed                                                | unilateral, usually in those with lighter skin color  | waxing and waning of size and pigmentation       | 50% with cellular atypia           | If larger than 2 clock hours: wide excision with cryotherapy, if not possible map biopsy  |
+^ Melanoma  | Denovo or arises from previous lesion above             | dark brown but may be amelanotic or mixed pigmentation  | elevated, thickened, nodular                                                      | unilateral                                            | highly vascular with feeder vessel often         | 35% develop metastasis by 5 years  | Complete excision with cryotherapy, metastatic workup                                     |
 ====Resources====
   - [[https://www.aao.org/eyenet/article/conjunctival-pigmented-lesions-diagnosis-managemen |Conjunctival Pigmented Lesions: Diagnosis and Management. Sayaad FFE et al. Eyenet September 2013]]
+  - [[https://pubmed.ncbi.nlm.nih.gov/14711437/ |Tumors of the conjunctiva and cornea. Shields CL, Shields JA. Surv Ophthalmol. 2004;49(1):3-24]]
+  - [[https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S003962572200039X?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS003962572200039X%3Fshowall%3Dtrue&referrer=https:%2F%2Fpubmed.ncbi.nlm.nih.gov%2F| Use of interferon alpha 2b to manage primary acquired melanosis and conjunctival melanoma. Cid-Bertomeu P, et al. Surv Ophthalmol. 2022;67(5):1391-1404]]