BMJ: first published as 10.1136/bmj.l6810 on 9 January 2020. Downloaded from http://www.bmj.

com/ on 16 January 2020 at Barts and The London - Queen Mary's School of Medicine and Dentistry.
BMJ 2020;368:l6810 doi: 10.1136/bmj.l6810 (Published 9 January 2020) Page 1 of 2

Endgames

ENDGAMES

CASE REVIEW

A pigmented lesion on the eye

1 15
Olivia M Bennett medical student , Rajesh C Rao assistant professor, ophthalmologist
1
Department of Ophthalmology & Visual Sciences, W K Kellogg Eye Center, University of Michigan, Ann Arbor, MI, USA; 2Department of Pathology,
University of Michigan, Ann Arbor, MI, USA; 3Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI, USA; 4A Alfred Taubman
Medical Research Institute, University of Michigan, Ann Arbor, MI, USA; 5Section of Ophthalmology, Surgical Service, Veterans Administration Ann
Arbor Healthcare System, Ann Arbor, MI, USA

A 46 year old white woman was referred for ophthalmologic What is seen in fig 1?

Protected by copyright.
evaluation of a pigmented lesion on the ocular surface of her A wedge shaped pigmented lesion with slight dome like
left eye. The lesion had been noted during a routine eye thickening of the conjunctiva (fig 2 *). Dilated, corkscrew
examination by her general practitioner. She had first noticed shaped feeder vessels abutted the lesion (fig 2, arrow head).
the lesion six years earlier, believing it to be gradually increasing
in size. Slit lamp biomicroscopy of the eye is shown in fig 1.
No cysts were noted within the lesion and no other lesions were
evident on complete ophthalmic examination, which included
eversion of the eyelids and retinal evaluation. The woman was
otherwise healthy.

Slit lamp biomicroscopy image of the left eye shows

pigmented lesion (asterisk) associated with a feeder vessel
(arrowhead)

2. What are the differential diagnoses?

Slit lamp biomicroscopy of the left eye
Differential diagnoses include benign conjunctival naevus,
conjunctival complexion associated melanosis, benign or
pre-cancerous forms of primary acquired melanosis, or
Questions malignant melanoma.1
1.What is seen in fig 1? A definitive diagnosis of conjunctival naevus, primary acquired
2.What are the differential diagnoses? melanosis, or malignant melanoma requires histopathology.2 3
Pre-cancerous primary acquired melanosis progresses into
3.What is the most likely diagnosis? melanoma in 13% of cases.2 Conjunctival complexion associated
melanosis is generally a clinical diagnosis associated with
Answers non-white ethnicities.4

1. 3.

Correspondence to R C Rao rajeshr@umich.edu

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
BMJ 2020;368:l6810 doi: 10.1136/bmj.l6810 (Published 9 January 2020)
What is the most likely diagnosis?
Primary acquired melanosis is most likely because the lesion is
flat and non-circumscribed. This condition is also more likely
to attract feeder vessels (fig 2),4 and it typically occurs in middle
aged individuals of white ethnicity.1 2 Confirmation of the
diagnosis, and determining whether it is benign or pre-cancerous
requires histopathological evaluation.
Benign conjunctival naevus and primary acquired melanosis
can both be similarly darkly coloured (brown or black).
However, naevi are often congenital or present from childhood,
contain cysts, and are well demarcated.4
The typical features of malignant melanoma (thickened,
elevated, or nodular lesions) are absent, making that condition
unlikely.1 Conjunctival complexion associated melanosis is also
unlikely because it is uncommon in white individuals.1
Learning points
• Refer all patients with pigmented ocular lesion(s) to an
ophthalmologist for close monitoring and consideration of
biopsy.
• Primary acquired melanosis can progress to malignant
melanoma.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Page 2 of 2
BMJ: first published as 10.1136/bmj.l6810 on 9 January 2020. Downloaded from http://www.bmj.com/ on 16 January 2020 at Barts and The London - Queen Mary's School of Medicine and Dentistry.
ENDGAMES
Patient outcome
This patient chose to defer biopsy and is instead monitored by
her ophthalmologist every 6-12 months with slit lamp
photography and ophthalmic examination.
Competing interests The BMJ has judged that there are no disqualifying financial
ties to commercial companies. The authors declare the following other interests:
none.
Further details of BMJ policy on financial interests are here: https://www.bmj.com/
about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-
interests
Patient consent obtained.
Provenance and peer review: not commissioned; externally peer reviewed.
1 Shields CL, Demirci H, Karatza E, Shields JA. Clinical survey of 1643 melanocytic and
nonmelanocytic conjunctival tumors. Ophthalmology 2004;111:1747-54.
10.1016/j.ophtha.2004.02.013 15350332
2 Shields JA, Shields CL, Mashayekhi A, etal . Primary acquired melanosis of the conjunctiva:
experience with 311 eyes. Trans Am Ophthalmol Soc 2007;105:61-71, discussion
71-2.18427595
3 Shields CL, Mashayekhi A, Cater J, Shelil A, Meadows AT, Shields JA. Chemoreduction
for retinoblastoma: analysis of tumor control and risks for recurrence in 457 tumors. Trans
Am Ophthalmol Soc 2004;102:35-44, discussion 44-5. 10.1016/j.ajo.2004.04.032 15747743
4 Shields CL, Shields JA. Tumors of the conjunctiva and cornea. Surv Ophthalmol
2004;49:3-24. 10.1016/j.survophthal.2003.10.008 14711437
Published by the BMJ Publishing Group Limited. For permission to use (where not already
granted under a licence) please go to http://group.bmj.com/group/rights-licensing/
permissions
Protected by copyright.
Subscribe: http://www.bmj.com/subscribe