DOI: https://doi.org/10.36347/sjmcr.2025.v13i11.021

Pages: 2748-2752

Primary Acquired Melanosis (PAM) with atypia is a rare but clinically significant precursor to conjunctival melanoma. We report a case of a 58-year-old female with multiple comorbidities who presented with persistent ocular redness and dryness, initially managed conservatively in primary care. Ophthalmologic evaluation revealed a vascularized temporal limbal conjunctival lesion with superficial corneal pigmentation. Ultrasound biomicroscopy demonstrated episcleral thickening (0.3–0.4 mm) over a 2.5 mm area, and MRI of the orbits and brain showed no intra orbital or intracranial extension. The lesion was excised using a “no-touch” technique with alcohol-assisted corneal epithelial removal and cauterization of the surgical bed. Histopathological analysis confirmed extensive PAM with high-grade atypia, with areas approaching melanoma in situ; superficial invasive melanoma could not be fully excluded. The patient remains under close ophthalmologic surveillance, with no evidence of recurrence to date. This case underscores the diagnostic challenges of PAM, especially in patients with non-specific ocular symptoms and prior eyelid surgery, where early malignant changes may be overlooked. Prompt recognition and surgical management are essential to prevent malignant transformation. The report highlights the importance of multidisciplinary coordination, appropriate imaging, and regular follow-up in managing high-risk conjunctival pigmented lesions to improve visual and oncologic outcomes.