Noninfectious conjunctival conditions

Last updated: February 10, 2023

Summarytoggle arrow icon

The conjunctiva are highly vascularized mucous membranes that line the inside of the eyelids and sclera. They are susceptible to a wide range of conditions, of which only degenerative, traumatic, and neoplastic ones are treated here (see “Eye and orbit” for more information on the anatomy of the eye and “Conjunctivitis” for inflammatory conditions). Pinguecula is a small, yellowish, raised plaque on the conjunctiva composed of protein, fat, or calcium. Pterygium is a benign, triangular, fibrovascular wedge of conjunctival tissue, which typically grows laterally starting from the nasal conjunctiva. Subconjunctival hemorrhage is a collection of blood between the conjunctiva and the sclera that is most commonly caused by trauma. Foreign bodies are a common source of ocular trauma, e.g., dust and debris that is propelled into the eye during activities such as grinding, drilling, sawing, or welding. Pigmented lesions include ocular melanosis, a benign, unilateral, congenital pigmentation of the episclera, and primary acquired melanosis, a benign, congenital pigmentation of the conjunctiva. Benign tumors of the conjunctiva include limbal dermoid, a congenital tumor in the region of the corneal limbus, and conjunctival nevus, a pigmented tumor of the conjunctiva. Malignant tumors include squamous cell carcinoma, a mainly keratinizing squamous cell carcinoma of the conjunctiva, conjunctival melanoma, a rare malignant tumor of the conjunctiva with a high rate of recurrence and metastasis, and conjunctival lymphoma, a salmon-pink colored, malignant tumor of the conjunctiva.

Pingueculatoggle arrow icon


Pterygiumtoggle arrow icon

  • Definition: a benign, triangular, fibrovascular wedge of conjunctival tissue, which typically grows laterally starting from the nasal conjunctiva
  • Epidemiology: more commonly occurs in areas with high UV radiation
  • Etiology
    • Chronic irradiation with UV light
    • Environmental irritation (e.g., hot, dry weather)
    • Genetic predisposition
  • Clinical features
    • Triangular, fibrovascular wedge of conjunctival tissue
      • Typically grows laterally starting from the nasal conjunctiva
      • Can extend to the cornea, leading to visual impairment
    • Symptoms of local irritation: scleral/corneal redness, lacrimation, foreign body sensation
    • Mild visual impairment
  • Differential diagnosis
  • Management [2][3]
  • Complications
    • Recurrence after surgical removal
    • Visual impairment
    • Reduced ocular motility
  • Prognosis
    • Good
    • Recurrence after surgical removal indicates a high risk of recurrence after subsequent procedures. [4]

Subconjunctival hemorrhage (SCH)toggle arrow icon


Pigmented lesions of the conjunctivatoggle arrow icon

Ocular melanosis (conjunctival melanosis) [7]

  • Definition: a benign, unilateral, congenital pigmentation (blue nevus) of the episclera
  • Epidemiology: more common in dark-skinned individuals
  • Etiology: accumulation of melanocytes in the eye
  • Clinical features
    • Iris heterochromia
    • Patchy slate-gray or bluish discoloration of the sclera
      • Usually unilateral
      • Subepithelial location without involvement of the conjunctiva (lesion is not displaceable with motion of the conjunctiva )
    • Increased pigmentation of the ipsilateral fundus
  • Management
    • Reassurance
    • Regular ophthalmic examination to monitor progression
  • Complications: increased risk of glaucoma and melanoma in the affected eye
  • Prognosis: The risk of progression to malignancy is ∼ 8%. [8]

Primary acquired melanosis (PAM)

  • Definition: a benign, congenital pigmentation of the conjunctiva
  • Epidemiology
    • Usually affects light-skinned individuals
    • Peak incidence at 50–60 years of age [9]
  • Clinical features
    • Flat, brown, irregularly arranged pigmentation
      • Displaceable with motion of the conjunctiva
      • Usually unilateral
      • Without cyst formation
  • Management
    • Small lesions: reassurance and regular ophthalmic examination to monitor progression
    • Mid-sized to large lesions: surgical excision and histopathologic examination
  • Complications: PAM with atypia may develop into conjunctival melanoma
  • Prognosis: increased risk of malignancy in PAM with atypia (up to 21%) [10]

Tumors of the conjunctivatoggle arrow icon

Benign tumors of the conjunctiva

Limbal dermoid (epibulbar dermoid) [11]

  • Definition
  • Clinical features
  • Management
    • In mild cases: reassurance and regular ophthalmic examination to monitor progression
    • In severe cases: surgical excision

Conjunctival nevus

  • Definition: a benign tumor of the conjunctiva that can vary in color from clear to dark brown depending on degree of pigmentation and often contains clear cysts
  • Epidemiology: most common benign tumor of the conjunctiva
  • Clinical features
    • Well-defined macula with small, clear inclusion cysts
      • Usually unilateral and most commonly in the lateral eyelid region
      • Pigmentation can be partial or complete
      • Pigmentation may increase or decrease with hormonal changes (e.g., pregnancy). [12]
  • Management
    • Reassurance
    • Regular ophthalmic examination to monitor progression
    • Surgical excision if the nevus is suspicious for malignancy or for cosmetic reasons
  • Prognosis: risk of malignancy is low (< 0.01%) [13]

Malignant tumors of the conjunctiva

Conjunctival squamous carcinoma [14]

Conjunctival melanoma [16]

Conjunctival lymphoma

Referencestoggle arrow icon

  1. Bell A. Pinguecula. J Vis Commun Med. 2006; 29 (2): p.82-83.doi: 10.1080/01405110600834168 . | Open in Read by QxMD
  2. Shahraki T, Arabi A, Feizi S. Pterygium: an update on pathophysiology, clinical features, and management. Therapeutic Advances in Ophthalmology. 2021; 13.doi: 10.1177/25158414211020152 . | Open in Read by QxMD
  3. Management of pterygium. Updated: February 1, 2023. Accessed: February 10, 2023.
  4. Kaufman SC, Jacobs DS, Lee WB, Deng SX, Rosenblatt MI, Shtein RM. Options and Adjuvants in Surgery for Pterygium. Ophthalmology. 2013; 120 (1): p.201-208.doi: 10.1016/j.ophtha.2012.06.066 . | Open in Read by QxMD
  5. Tarlan B, Kiratli H. Subconjunctival hemorrhage: risk factors and potential indicators. Clinical Ophthalmology. 2013.
  6. Doshi R, Noohani T. Subconjunctival hemorrhage. StatPearls. 2020.
  7. Zhong J, Deng Y, Zhang P, et al. New Grading System for Limbal Dermoid: A Retrospective Analysis of 261 Cases Over a 10-Year Period.. Cornea. 2018; 37 (1): p.66-71.doi: 10.1097/ICO.0000000000001429 . | Open in Read by QxMD
  8. Pache M, Glatz-Krieger K, Sauter G, Meyer P. Expression of sex hormone receptors and cell cycle proteins in melanocytic lesions of the ocular conjunctiva. Graefe's Archive for Clinical and Experimental Ophthalmology. 2005; 244 (1): p.113-117.doi: 10.1007/s00417-005-0035-2 . | Open in Read by QxMD
  9. Shields CL, Fasiuddin AF, Mashayekhi A, Shields JA. Conjunctival nevi: clinical features and natural course in 410 consecutive patients.. Archives of ophthalmology (Chicago, Ill. : 1960). 2004; 122 (2): p.167-75.doi: 10.1001/archopht.122.2.167 . | Open in Read by QxMD
  10. Gichuhi S, Sagoo MS. Squamous cell carcinoma of the conjunctiva.. Community eye health. 2016; 29 (95): p.52-53.
  11. Edgar A, Crutchfield G, Anderson N. Superficial radiotherapy as a treatment alternative for recurrent conjunctival squamous cell carcinoma: a case study. Journal of Medical Radiation Sciences. 2018; 65 (3): p.240-244.doi: 10.1002/jmrs.274 . | Open in Read by QxMD
  12. Patel DR, Patel BC. Ocular Melanoma. StatPearls. 2021.
  13. Kenawy N, Lake SL, Coupland SE, Damato BE. Conjunctival melanoma and melanocytic intra-epithelial neoplasia.. Eye. 2013; 27 (2): p.142-52.doi: 10.1038/eye.2012.254 . | Open in Read by QxMD
  14. Tanenbaum RE, Galor A, Dubovy SR, Karp CL. Classification, diagnosis, and management of conjunctival lymphoma. Eye and Vision. 2019; 6 (1).doi: 10.1186/s40662-019-0146-1 . | Open in Read by QxMD
  15. Shields JA, Shields CL. Intraocular Tumors. Lippincott Williams & Wilkins ; 2008
  16. Shields CL, Kaliki S, Hutchinson A, et al. Iris nevus growth into melanoma: analysis of 1611 consecutive eyes: the ABCDEF guide.. Ophthalmology. 2013; 120 (4): p.766-72.doi: 10.1016/j.ophtha.2012.09.042 . | Open in Read by QxMD
  17. Shields JA, Shields CL, Mashayekhi A, et al. Primary acquired melanosis of the conjunctiva: experience with 311 eyes.. Trans Am Ophthalmol Soc. 2007; 105: p.61-71; discussion 71-2.
  18. Grehn F. Augenheilkunde. Springer Verlag (2005) ; 2006
  19. Lang GK, et al.. Augenheilkunde. Thieme Verlag (2008) ; 2008

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