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   Table of Contents      
Year : 2019  |  Volume : 67  |  Issue : 11  |  Page : 1792

A simple pingueculum or not?

Wills Eye Hospital, Philadelphia, PA, USA

Date of Web Publication22-Oct-2019

Correspondence Address:
Dr. Carol L Shields
Oncology Service, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut Street, Suite 1440, Philadelphia, PA 19107-5109
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1831_19

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How to cite this article:
Marks V, Lally SE, Shields CL. A simple pingueculum or not?. Indian J Ophthalmol 2019;67:1792

How to cite this URL:
Marks V, Lally SE, Shields CL. A simple pingueculum or not?. Indian J Ophthalmol [serial online] 2019 [cited 2022 Jul 4];67:1792. Available from: https://www.ijo.in/text.asp?2019/67/11/1792/269619

  Case Top

A 75-year-old Caucasian male developed redness on the surface of the right eye (OD) [Figure 1]a that persisted for 6 months. Surgical excision revealed amelanotic conjunctival melanoma without primary acquired melanosis [Figure 1]b. Eight years later, he noted mild recurrent redness on the opposite side of the OD, appearing as an inflamed pingueculum [Figure 1]c.
Figure 1: An amelanotic mass with feeder and fine intrinsic vessels at the 1 o'clock bulbar conjunctiva of the right eye (a). Histopathology confirmed the diagnosis of conjunctival melanoma (b). Years later a new lesion appeared at the 9 o'clock limbus resembling a pingueculum (c). Histopathology again revealed amelanotic melanoma (d)

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  What Is Your Next Step? Top

  1. Prescribe topical nonsteroidal anti-inflammatory drugs
  2. Prescribe topical corticosteroids
  3. Perform cryotherapy
  4. Perform “no touch” surgical excision.

  Findings Top

“No touch” surgical excision (D) was performed, as there was suspicion for amelanotic melanoma recurrence. Histopathology revealed a segment of conjunctiva containing nests and sheets of atypical small epithelioid and spindle amelanotic melanocytes in the substantia propria, consistent with recurrence of the previously diagnosed conjunctival melanoma [Figure 1d]. All margins were clear. The specimen was sent for biomarker testing, which revealed pathogenic NRAS mutation and no mutation in BRAF or c-KIT biomarkers.

  Diagnosis Top

Conjunctival amelanotic melanoma.

  Correct Answer : D. Top

  Discussion Top

Conjunctival malignant melanoma (CMM) represents 0.25% of melanomas.[1] Typical management includes complete surgical resection and cryotherapy.[2] Adjuvant therapy is considered to prevent tumor recurrence and metastasis.[2] Wong et al. reported up to 45% local recurrence and 42% systemic metastasis in 5 years.[1] Similar to cutaneous melanoma, CMM has been associated with BRAF, c-KIT, and NRAS mutations.[2]NRAS mutations have been associated with more aggressive disease and decreased survival.[3] While no approved NRAS-specific targeted therapies are currently available, immune-based therapies such as interleukin-2 (IL-2), anti-CTLA4 antibody (ipilimumab), and anti-PD1 treatment (nivolumab and pembrolizumab) are now first-line treatments for NRAS-mutated cutaneous melanoma.[3]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Wong JR, Nanji AA, Galor A, Karp CL. Management of conjunctival malignant melanoma: A review and update. Expert Rev Ophthalmol 2014;9:185-204.  Back to cited text no. 1
Shields CL, Chien JL, Surakiatchanukul T, Sioufi K, Lally SE, Shields JA1. Conjunctival tumors: Review of clinical features, risks, biomarkers, and outcomes – The 2017 J. Donald M. Gass Lecture. Asia-Pac J Ophthalmol 2017;6:109-20.  Back to cited text no. 2
Boespflug A, Caramel J, Dalle S, Thomas L. Treatment of NRAS-mutated advanced or metastatic melanoma: Rationale, current trials and evidence to date. Ther Adv Med Oncol 2017;9:481-92.  Back to cited text no. 3


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