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conjunctival_pigmented_lesions [2026/02/25 18:36] – Scott Larsonconjunctival_pigmented_lesions [2026/02/25 19:50] (current) – Scott Larson
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 ====== Conjunctival Pigmented Lesions ====== ====== Conjunctival Pigmented Lesions ======
-FIXME+
 ====Nevi==== ====Nevi====
   * Usually appear in childhood   * Usually appear in childhood
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 ===Complexion Associated Melanosis (CAM)=== ===Complexion Associated Melanosis (CAM)===
 +  * Bilateral perilimbal pigmentation in darkly pigmented inviduals
 +  * Doesn't progress to melanoma
  
 ===Primary Acquired Melanosis (PAM)=== ===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=== ===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==== ====Summary Table====
-^ Type      ^ History  ^ Color  ^ Appearance  ^ Laterality  ^ Specific Features  ^ Chance of Maligancy  ^ Primary Management  ^ +^ Type      ^ History                                                 ^ Color                                                   ^ Appearance                                                                        ^ Laterality                                            ^ Specific Features                                ^ Chance of Maligancy                ^ Primary Management                                                                        ^ 
-^ Nevus     |          |        |             |             |                    |                      |                     | +^ 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       |          |        |             |             |                    |                      |                     | +^ 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       |          |        |             |             |                    |                      |                     | +^ 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  |          |        |             |             |                    |                      |                     |+^ 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==== ====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://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]]