Most ocular “freckles” are safer to monitor than to remove. Intervention becomes appropriate when objective thresholds are crossed, typically when a lesion shows suspicious change, has high-risk clinical features, or causes diagnostic uncertainty that cannot be resolved with imaging alone. ³
For conjunctival lesions, biopsy/treatment is more common than for intraocular lesions because tissue can be obtained directly. Features that lower the threshold for excision include:
- Nodularity or thickening
- New feeder vessels
- Rapid enlargement or colour change
- Atypical sites (fornix, tarsal conjunctiva, caruncle)
- A flat, patchy adult-onset pattern suggestive of primary acquired melanosis (PAM) ²
For PAM, histology (presence and grade of atypia) and extent guide management. Diffuse disease may require excision with cryotherapy and/or topical chemotherapy under specialist care. ¹ ²
For choroidal tumours, biopsy is less common; decisions are usually imaging-based. When multiple validated risk factors accumulate, early referral and definitive treatment may be recommended rather than prolonged observation. ³
References
- Wong JR, Nanji AA, Galor A, Karp CL. Management of conjunctival melanoma and primary acquired melanosis. Clinical Ophthalmology. 2014;8:197-206. doi:10.2147/OPTH.S45987. PMID: 25580155.
- Shields JA, Shields CL, Mashayekhi A, Marr BP, Benavides R, Thangappan A, et al. Primary acquired melanosis of the conjunctiva: experience with 311 eyes. Ophthalmology. 2008;115(3):511-519.e2. doi:10.1016/j.ophtha.2007.07.003. PMID: 17884168.
- Shields CL, Demirci H, Materin MA, Marr BP, Mashayekhi A, Shields JA. Clinical factors in the identification of small choroidal melanoma. Canadian Journal of Ophthalmology. 2004;39(4):351-357. doi:10.1016/S0008-4182(04)80005-X. PMID: 15327099.
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