CASE 4. A black eye: melanoma in situ of the conjunctiva.

A 77-year-old woman consulted an ophthalmologist because her left eye had “turned black” during the last 6 to 9 months. In addition, she felt that her eye was “sinking in the orbit.” Visual acuity was reduced to 20/30. The right eye was normal with 20/20 vision. The nasal, temporal, and especially, the upper conjunctiva (Fig 1A) of her left eye contained literally myriad dark brown pigment deposits that also extended to the eyelid skin at the upper lid margin (Fig 1A; arrowheads) and to the cornea (Fig 1A; double arrowhead). On eversion of the upper eyelid, the tarsal conjunctiva was found to be involved (Fig 1B). In its central area, the pigment deposits formed a confluent, nonelevated patch (Fig 1B; arrowhead). One month later, an ocular oncologist confirmed that the melanosis was confined to the conjunctival epithelium and had not caused conjunctival thickening. The eyelid crease was inconspicuous, suggesting ptosis. The diagnosis was primary acquired melanosis of the conjunctiva with atypia. Close follow-up was recommended. The patient was reviewed for conjunctival thickening at 2to 6-month intervals for a year and a half, during which time the melanosis progressed with waxing and waning; the deposits decreased in some areas (Fig 1C; arrowheads) and increased in others (Fig 1D; arrowhead). Because of the extent of the melanosis, it could not be removed by surgery. Cryotherapy and irradiation were also impractical. Topical chemotherapy, 0.2 mg/mL mitomycin diluted in commercial artificial tears four times a day, was consequently started. Two-week-long courses separated by an interval of 3 weeks were planned. The eye became irritated during the second course, which was stopped after 1 week. The irritation disappeared quickly with a topical corticosteroid preparation. The melanotic areas gradually regressed and the pigment deposits rarefied. The patient was reviewed for the last time 14 months after start of chemotherapy, by which time the bulbar conjunctiva and cornea were almost free of melanosis (Fig 1E), which had also disappeared from the nasal eyelid margin (Fig 1E; arrowheads). The confluent patch in the tarsal