Pigmented lesion on palpebral conjunctiva

Hi Dr.,

I am of South Asian descent (not very light or dark skinned - sort of in the middle).  30 year old male.  A few days ago, I noticed a small pigmented lesion on the tarsal conjunctival area of my lower eyelid (i.e., inner surface of the eyelid).  It is on the outer end of the eye (i.e., away from the nose).  The lesion is small and oblong - about 2mm in length.  It is NOT raised.  The color seems even/light brown.  In other words, if I saw this lesion anywhere on my skin, I probably would not think twice, but the location worries me.

The location worries me because all the literature I have read seems to say the same thing:  any pigmented lesion in this area (tarsal palpebral conjunctiva) is by definition a melanoma (or primary aquired melanosis) until proven otherwise.  They say that nevi are extremely rare in this area, so such lesions must be PAMs or melanoma.

I saw a Bascom-educated opthalmologist/eyelid surgeon yesterday for evaluation.  He looked at it under the slit lamp and said he wouldn't worry about it because it wasn't raised.  He said it's a melanosis- not a nevus- and that it's common for ethnic minorities like myself to get these.  He said to come back in 6 mos and just keep an eye on it.

I have trouble accepting the doctor's explanation because I know that lesions related to skin color tend to occur bilaterally and on the sclera of the eye, not unilaterally and on the palpebral conjunctiva.  

Questions:
1) Do you see such lesions on the palpebral conjunctiva commonly in your practice?

2) Realizing that you have not examined me, would this fact pattern cause you alarm (bearing in mind my age and racial background)?

3) Are you of the opinion that the literature is a bit extreme in what it says about these lesions on tarsal conjunctiva almost definitely being melanoma/PAM?

I'm just very worried and would like a more detailed answer than what my dr gave me.

Thank you for your efforts and this website.

[Ray T Oyakawa, MD]

I would agree with your doctor.   These lesions are not common.   Melanoma in Asians are extremely uncommon.

Dr. O.