Conjunctival Pigmented Lesions

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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 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

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.

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