Benign pigmented tumorous lesions located in the bulbar conjunctiva.
Bulbar conjunctiva (M/C, 72% cases)
Clinical features
Benign lesions with wide variation in clinical and histopathological features:
Variations in pigmentation of conjunctival nevi. A, Heavily pigmented conjunctival nevus. B, Lightly pigmented conjunctival nevus. | Shields, C. L., Fasiudden, A., Mashayekhi, A., & Shields, J. A. (2004). Conjunctival Nevi: Clinical Features and Natural Course in 410 Consecutive Patients. Archives of Ophthalmology, 122(2), 167–175. https://doi.org/10.1001/archopht.122.2.167Variations in size of conjunctival nevi. A, Small, pigmented conjunctival nevus measuring approximately 1 mm in basal diameter. B, Giant conjunctival nevus measuring 18 mm in basal diameter. | Shields, C. L., Fasiudden, A., Mashayekhi, A., & Shields, J. A. (2004). Conjunctival Nevi: Clinical Features and Natural Course in 410 Consecutive Patients. Archives of Ophthalmology, 122(2), 167–175. https://doi.org/10.1001/archopht.122.2.167Variations in location of conjunctival nevi. A, The most common location of the conjunctival nevus is on the bulbar conjunctiva at the limbus. B, The second most common location of the conjunctival nevus is in the caruncle. C, The least common location of the conjunctival nevus is in the plica semilunaris. | Shields, C. L., Fasiudden, A., Mashayekhi, A., & Shields, J. A. (2004). Conjunctival Nevi: Clinical Features and Natural Course in 410 Consecutive Patients. Archives of Ophthalmology, 122(2), 167–175. https://doi.org/10.1001/archopht.122.2.167Variations in associated clinical features of conjunctival nevi. A, Pigmented nevus with prominent clear intralesional cysts. B, Lightly pigmented nevus with pigment-lined intralesional cysts.C, Non-pigmented nevus with clear intralesional cysts and dilated feeder vessel.D, Lightly pigmented nevus with prominent vascularity. | Shields, C. L., Fasiudden, A., Mashayekhi, A., & Shields, J. A. (2004). Conjunctival Nevi: Clinical Features and Natural Course in 410 Consecutive Patients. Archives of Ophthalmology, 122(2), 167–175. https://doi.org/10.1001/archopht.122.2.167Variations in the clinical appearance of the 4 histopathologic subtypes of conjunctival nevi. A, Compound nevus of the conjunctiva. B, Subepithelial nevus of the conjunctiva. C, Blue nevus of the conjunctiva. | Shields, C. L., Fasiudden, A., Mashayekhi, A., & Shields, J. A. (2004). Conjunctival Nevi: Clinical Features and Natural Course in 410 Consecutive Patients. Archives of Ophthalmology, 122(2), 167–175. https://doi.org/10.1001/archopht.122.2.167Change in nevus appearance overtime. A, May 1988. Pigmented conjunctival nevus at the limbus in a 26-year-old woman. B, July 1990. Several years later the conjunctival nevus of the same woman was less pigmented and barely visible. | Shields, C. L., Fasiudden, A., Mashayekhi, A., & Shields, J. A. (2004). Conjunctival Nevi: Clinical Features and Natural Course in 410 Consecutive Patients. Archives of Ophthalmology, 122(2), 167–175. https://doi.org/10.1001/archopht.122.2.167
Diagnosis
Imaging
Anterior Segment Optical Coherence Tomography:
Clinical Features and Imaging With Anterior Segment Optical Coherence Tomography of Giant Conjunctival Nevus: A, A 16-year-old white male demonstrated a giant conjunctival nevus with slight pigmentation superonasally measuring 20 mm in basal diameter and 4 mm in thickness. B, On anterior segment optical coherence tomography (AS OCT), the intralesional cysts were confirmed. C, A 48-year-old white man showed giant conjunctival nevus superotemporally measuring 18 mm in basal diameter and 2 mm in thickness. D, On AS OCT, the intralesional cysts were confirmed. | Shields, C. L., Regillo, A. C., Mellen, P. L., Kaliki, S., Lally, S. E., & Shields, J. A. (2013). Giant Conjunctival Nevus: Clinical Features and Natural Course in 32 CasesGiant Conjunctival NevusGiant Conjunctival Nevus. JAMA Ophthalmology, 131(7), 857–863. https://doi.org/10.1001/jamaophthalmol.2013.160
Histopathology
(A) Magnified slit-lamp image showing the pigmented lesion with numerous small cysts. (B) Histopathological slide of the tumor stained with H&E, ×20. (C) Histopathological slide of the tumor stained with H&E, ×50. Numerous nests of nevus cells containing abundant melanin pigment can be seen under the conjunctival epithelium. | Röck, T., Bösmüller, H.-C., Bartz-Schmidt, K. U., & Röck, D. (2018). Surgical management of a conjunctival nevus with amniotic membrane transplantation. International Medical Case Reports Journal, 11, 161–165. https://doi.org/10.2147/IMCRJ.S164099
Differential diagnosis
Melanoma
Clinical features suggestive of possible melanoma:
Older patient ageat recognition of nevus
Corneal, forniceal, or palpebral involvement
Prominent feeder vessels
Lack of intrinsic cysts
Personal/family history of cutaneous melanoma
Dysplastic nevus syndrome
Differential Diagnosis of Giant Conjunctival Nevus: A, Giant pigmented conjunctival nevus measuring 23 × 12 × 2 mm, with prominent intralesional cysts. B, Diffuse primary acquired melanosis in an African American woman with dark pigment dusting involving the entire bulbar conjunctiva. C, Pigmented conjunctival melanoma measuring 6 × 5 × 4 mm at the limbus with associated primary acquired melanosis involving inferior bulbar and forniceal conjunctiva. D, Conjunctival lymphangiectasia with associated subconjunctival hemorrhages. | Shields, C. L., Regillo, A. C., Mellen, P. L., Kaliki, S., Lally, S. E., & Shields, J. A. (2013). Giant Conjunctival Nevus: Clinical Features and Natural Course in 32 CasesGiant Conjunctival NevusGiant Conjunctival Nevus. JAMA Ophthalmology, 131(7), 857–863. https://doi.org/10.1001/jamaophthalmol.2013.160
Management
Observation (M/C)
Excisional biopsy alone ± cryotherapy
Indication: Concern for malignant change based on clinical features:
Recent growth
Colour change
Recurrence of previously excised lesion
(A) Color photograph of the surgical video after the application of topical anesthesia (five drops of a single dose of 0.4% oxybuprocaine hydrochloride). (B and C) Subconjunctival anesthesia with 2% mepivacaine. (D) The conjunctival tumor was resected using a wide excisional biopsy with a tumor safety distance of 2.0 mm. The resection was performed using the “no-touch” technique. (E) The 12 mm × 10 mm conjunctival defect. (F) The AM was placed with the stromal side facing down toward the defect. The AM was secured to the surrounding conjunctiva by five interrupted 9-0 Vicryl sutures. | Röck, T., Bösmüller, H.-C., Bartz-Schmidt, K. U., & Röck, D. (2018). Surgical management of a conjunctival nevus with amniotic membrane transplantation. International Medical Case Reports Journal, 11, 161–165. https://doi.org/10.2147/IMCRJ.S164099Slit-lamp images showing the course of healing over time: (A) Slit-lamp image showing the large pigmented lesion before surgery. (B) Seven days after the resection and AMT. (C) A slit-lamp examination revealed stable findings 6 months after surgery. The AM has been partly integrated into the host tissue, while the ocular surface inflammation and corneal vascularization have decreased. (Abbreviations: AM, amniotic membrane; AMT, AM transplantation) | Röck, T., Bösmüller, H.-C., Bartz-Schmidt, K. U., & Röck, D. (2018). Surgical management of a conjunctival nevus with amniotic membrane transplantation. International Medical Case Reports Journal, 11, 161–165. https://doi.org/10.2147/IMCRJ.S164099
