Pigmented lesions of the conjunctiva include the entities nevus, racial melanosis, primary acquired melanosis with and without atypia, and melanoma. Melanoma is a malignant tumor that requires aggressive treatment. Several of the other pigmented lesions of the conjunctiva are benign and justify a less aggressive treatment or serial observation. The diagnosis and management of pigmented conjunctival lesions can be challenging to the ophthalmologists because of overlapping features between melanoma and the benign lesions nevus, racial melanosis, and primary acquired melanosis. In addition, primary acquired melanosis with atypia and nevus have the potential to develop into melanoma and thus need to be managed carefully. Pearls for the diagnosis and management of conjunctival pigmented lesions are presented.
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