1. Epibulbar lesions

2. Classification of the Epibulbar Lesions
There are two types of the epibulbar lesions that include the pigmented and the non-pigmented lesions. These lesions are further classified into benign, premalignant and malignant lesions.
Benign Epibulbar Lesions : conjunctival naevus, conjunctival
papilloma, dermoid, dermolipoma, pyogenic granuloma, and conjunctival epithelial melanosis
Malignant and Premalignant Epibulbar Lesions : primary acquired melanosis, melanoma, ocular surface squamous neoplasia, lymphoproliferative lesions and kaposi’s sarcoma.
The other classification based on clinical classification (eTNM) or patholgical classification (pTNM) which show the clinical and pathologic features of the lesions and how extend it is .

4. PIGMENTED EPIBULBAR LESIONS
The pigmented lesions can be either benign or malignant.
These lesions include: conjunctival epithelial melanosis, conjunctival freckle, primary acquired melanosis (PAM), conjunctival nevus, congenital ocular melanocytosis, melanoma and Orbital melanomas.

5. Conjunctival nevus Anatomical Location : Interpalpebral limbus usually
Color: Brown or yellow
Depth: Stroma
Margins : Well defined Laterality Unilateral
Treatment : observation
- local excision
- terminal stage by malignant transformation exenteration of the orbit, chemotherapy
Progression : 1% progress to limbus usually conjunctival melanoma

6. Conjunctival epithelial melanosis
Anatomical Location: Limbus bulbar palpebral conjunctiva
Color: yellow-brown or brown-black
Depth: Epithelium
Laterality: Bilateral
Treatment : Surgical excision
Progression : very rare progression to conjunctival melanoma

7. Primary acquired melanosis (PAM)
Anatomical Location: Anywhere, but usually bulbar conjunctiva
Color: Brown
Depth: Epithelium
Laterality: Bilateral
Treatment : small lesions –excisional biopsy
large excision – large defects after excision or cryotherapy
Progression : Progresses to conjunctival melanoma in nearly 50%
cases that show cellular atypia

8. Malignant melanoma Anatomical Location: Anywhere Color: Brown or pink
Depth: Stroma
Margins: Well defined Laterality: Unilateral
Treatment : excision or exenteration of the orbit or brachytherapy
Progression : 32% develop metastasis by 15 years

9. Non-Pigmented Epibulbar Lesions
The non-pigmented lesions are the lesions that do not have pigmentation and they are transparent or translucent due to the absence of pigmentation that renders color to the lesion.
These lesions include: papilloma epibulbar choristoma, pyogenic granuloma, conjunctival intraepithelial neoplasia (carcinoma in situ, dysplasia), conjunctival squamous cell carcinoma, conjunctival Kaposi’s sarcoma, conjunctival lymphoma, mucoepidermoid carcinoma, and infiltration from lid tumors.

10. Conjunctival Papilloma
- located frequently in the caruncle, fornix and juxtalimbal region.
- bilateral or multifocal
-Small lesions do not require treatment as they resolve spontaneously. Cryotherapy and wide margin can be performed to excise the circumscribed lesions, mitomycin and administration of oral cimetidine.
- Recurrence 6-27%

11. Conjunctival Intraepithelial Neoplasia
3 clinical variants:
Papilliform
Gelatinous
Leukoplakic
Anatomical Location: Exposed areas of bulbar conjunctiva, at or near limbus.
Treatment:
1-Excisional biopsy with adjunctive cryotherapy Recurrence rates at 10 year 33-50%.
2-Topical chemotherapeutic agents

12. Mucoepidermoid Carcinoma
Anatomical Location: limbal conjunctiva, fornix, or caruncle
Epithelial origin
Treatment:
– Wide surgical excision
– Adjuvant therapy: cryotherapy, radiation

13. Pyogenic Granuloma
- Rapidly growing red, pedunculated, smooth lesion
- Bleeds easily and stains with
fluorescein dye
Treatment: 1- Topical or intralesional corticosteroids may be
curative
2– Excision with cauterization to the base, primary
closure and post-op steroids to minimize recurrence.

14. Conjunctival Kaposi Sarcoma
- Malignant neoplasm of vascular endothelium
- Inferior fornix most common
Treatment:Surgical debulking
– Cryotherapy
– Radiotherapy
– Local or systemic chemotherapy

15. Thank you for your attention