3.11 Pigmented Lesions, Conjunctival

eyes.nhs.scot/
Eyecare Guidelines/
Section 3 - Conjunctiva/
3.11 Pigmented Lesions, Conjunctival

Date of last review:

5/9/2026

Date of next review:

5/9/2028

Date of publication:

16/9/2026

Differential diagnosis ⁽¹⁾ 

Conjunctival intraepithelial squamous neoplasia (CIN), which may resemble amelanotic melanoma 
Blue naevus, a rare, deeply pigmented congenital lesion that may mimic Primary Acquired Melanosis (PAM) or melanoma

Possible management by optometrist

Advice ⁽¹⁾

Provide general advice on ocular UV protection 
Careful documentation and monitoring are essential, including photography where possible

Lesion‑Specific Guidance 

Ethnic Melanosis 

No malignant potential 
Management 
- Reassure patient 
- No treatment or referral required

Primary Acquired Melanosis (PAM) / Conjunctival Melanocytic Intraepithelial Neoplasia (C‑MIN) 

May carry risk of malignant transformation (reported up to ~13%) 
Management 
- Routine referral to ophthalmology for assessment 
- Diagnosis requires histopathology (biopsy) to determine atypia

Congenital Ocular Melanocytosis 

Associated with increased risk of uveal melanoma 
May involve pigmentation of other ocular structures (e.g. trabecular meshwork), with risk of secondary glaucoma 
Management 
- Routine referral to ophthalmology 
- Requires ongoing monitoring, including:  
  - Fundus examination (with dilation) 
  - Surveillance for glaucoma

Conjunctival Naevus 

Usually benign; malignant transformation is rare 
Management 
- No treatment required if stable 
- Advise patient to report:  
  - Increase in size 
  - Change in colour 
  - Development of elevation or vascularity 
Routine review at subsequent eye examinations 
Photo‑documentation recommended

Referral indicated if: 

Lesion is enlarging, darkening, inflamed, or developing new vessels 
Located in forniceal or palpebral conjunctiva (higher suspicion of malignancy)

Conjunctival Melanoma 

Potentially sight‑ and life‑threatening 
May spread by local invasion and via lymphatics
Management 
- Urgent referral to ophthalmology (suspected malignancy pathway) 
- Examine regional lymph nodes (preauricular, submandibular)

Treatment  ⁽¹⁾

No treatment in primary eye care setting

Typical dosage/duration

(Blue text = IP, black text = non-IP)

Not applicable for this condition

Further management options

No referral required ⁽¹⁾
- Mild ethnic melanosis

Routine Referral to Ophthalmology ⁽¹⁾
- PAM / C‑MIN 
- Congenital ocular melanocytosis 
- Naevus with suspicious features (growth, colour change, vascularity, atypical location)

Urgent Referral  to ophthalmology
- Suspected conjunctival melanoma ⁽¹⁾
- Refer in line with local suspected cancer pathways ⁽⁷⁾

Possible management in secondary care or local/community pathways where available

See Further management options ⁽⁷⁾ 
PAM / C‑MIN ⁽¹⁾:  
- Multiple biopsies to assess malignant potential  
Melanoma ⁽¹⁾:  
- Surgical excision (often en bloc) 
- Adjuvant therapies (e.g. mitomycin C, radiotherapy, topical chemotherapy) 
- Ongoing surveillance for recurrence and metastasis

College of Optometrists Clinical Management Guideline⁽¹⁾ 

Conjunctival pigmented lesions - College of Optometrists *

* With special thanks to The College of Optometrists for providing the evidence framework for diagnosis and management from the Clinical Management Guidelines (CMGs) for this condition. All references to the College/CMGs are included where appropriate and form the basis of the Community Eyecare Guidelines.

Guidance is informed by the following sources

College of Optometrists Clinical Management Guidelines Clinical Management Guidelines - College of Optometrists
Advisory alignment with the College of Optometrists Formulary Optometrists' Formulary - College of Optometrists
Advisory alignment with the BNF BNF (British National Formulary) | NICE
Advisory alignment with the Summary Product Characteristics taken from the EMC Home - electronic medicines compendium (emc)
Advisory alignment with Scottish Health Board formularies (where a clear majority is present) *
Advisory alignment with expert consensus (CEGG), informed by sources 2-5 above
Advisory alignment with expert consensus (CEGG)
“Annex C of the Statement” https://www.eyes.nhs.scot/for-professionals/legislation/

* Scottish formularies should be available within the Prescribing section of your Health Board pages on the eyes.nhs.scot website. If unavailable, contact your local Health Board for further information; Health Boards landing page

If you have a query relating to this page, please email NSS.ComEyecareGuidelineGroup@nhs.scot

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