Case #12: PAM With Atypia

By Paul T. Finger, MD


Pigmented tumor could be seen involving the plica and inferior fornix.
Pigmented tumor could be seen involving the plica and inferior fornix. Extensive involvement of the lower eyelid suggests diffuse involvement of the conjunctiva (beyond the pigmented margins).

PAM with Atypia with Eyelid Extension.

*Note* This risks and benefits of observation, exenteration, excision with and without cryotherapy and/or topical mitomycin, as well as radiation were discussed with this patient in detail. Primary excision with subsequent topical mitomycin therapy was recommended and performed. The nodular and resectable areas were removed. Topical mitomycin was employed to address the residual diseased epithelium.


This case presents several classic findings of PAM as well as the unusual finding of extension onto the lower eyelid. Other findings of conjunctival melanomas and primary acquired melanosis include thickness, neovascularization, and corneal epithelial extension. Intraocular extension is very rare, but should this tumor recur, orbital invasion is not uncommon.

Your Questions or Comments

3 months after resection (conjunctival and eye lid)
These photographs were taken 3 months after resection (conjunctival and eye lid) followed by topical mitomycin chemotherapy. Despite this excellent result, this patient is at risk for recurrent melanoma.

Melanie Kazlas, M.D.
Director of Pediatric Ophthalmology
Boston Medical Center

Question: Yesterday I saw a 10 year old Hispanic/African American child for a routine visit. He had salt and pepper melanosis in the inferior fornix OS>OD as well as a flat pigmented lesion of the nasal inferior tarsal conjunctiva (2x2mm). I often see perilimbal melanosis in my darkly pigmented patients. Can my patient also be classified as having “racial” melanosis?

Answer: I too see a lot of racial melanosis. As a general rule, if it is bilateral, it is probably racial melanosis. As you have noted (unlike your case) racial melanosis primarily involves the bulbar conjunctiva. It is also important to know that nevi can grow during puberty.

In general, I photograph and follow most of these patients. Photography has been made relatively inexpensive and easier by digital technology. My threshold for biopsy of suspicious or growing lesions is low. Make sure an ophthalmic pathologist sees the specimen.

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