Most conjunctival pigmented lesions are benign, but some patterns require a higher index of suspicion. Red flags include:
- Adult-onset, flat, patchy pigment suggestive of primary acquired melanosis (PAM) rather than a long-standing naevus ¹
- Hidden locations: fornix, tarsal conjunctiva, caruncle (less typical for benign conjunctival naevi)
- New feeder vessels, nodularity, thickening, ulceration, or inflammation
- Documented change in size or colour over serial photos
Population-based data show that conjunctival tumours are more often benign than malignant overall, but malignant lesions do occur, so the aim is to identify the minority that warrant specialist-led management. ²
PAM is particularly important because atypia and extent are linked to melanoma risk, and clinical appearance alone may not reliably predict histology. ¹ ³ For this reason, suspicious conjunctival pigment should be managed with baseline high-resolution photography, clear mapping of involved areas, and referral to ocular oncology when features suggest PAM with atypia or melanoma-suspect change.
References
- 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.
- Dalvin LA, Salomão DR, Patel SV. Population-based incidence of conjunctival tumors in Olmsted County, Minnesota. British Journal of Ophthalmology. 2018;102(12):1728-1734. doi:10.1136/bjophthalmol-2017-311530. PMID: 29511061.
- 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.
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