====== Conjunctival Pigmented Lesions ======

====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]]