Correspondence Address:
Amol Ganvir
Department of Ophthalmology, Lokmanya Tilak Municipal Medical College and General Hospital, Dr Babasaheb Ambedkar Road, Sion, Mumbai - 400 022, Maharashtra
India

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Sir,

Conjunctival pigmentations are most deceptive lesions in clinical practice. It is important to distinguish it from nevus, racial melanosis, primary acquired melanosis, ocular melanocytosis, and conjunctival melanoma. Size, shape, margins, extent, locations, course of the lesion, and histopathology analysis narrow down the confusion, and of course, proper history also gives a clue in the diagnosis. Racial melanosis is a bilateral condition characterized by with flat pigmentation and poorly defined margins. It is commonly seen at the limbus. Conjunctival nevus lesions are slightly elevated, sessile and contain stromal cyst.[1] Primary acquired melanosis has typical flat lesion located near the limbus with poorly defined margins. Conjunctival melanoma is elevated, pigmented, and well-defined lesion. Ocular melanocytosis is a congenital lesion which has flat pigmentation involving the sclera.[2]

We hereby describe a condition which was mimic like nevus, primary acquired melanosis. A 55-year-old male patient came with conjunctival black pigmentations in both eyes. Lesions were elevated with irregular margin [Figure 1] and Video 1]. The same elevated lesion scattered below both eyelid skins. There was a history of intermittent shedding of black dots, and kohl along lid margins aroused suspicion. With sterile cotton bud, embedded kohl particles were removed from the fornices [Figure 2]. One should always keep in mind when we met with conjunctival pigmentation, embedded kohl could be one of the differential diagnosis.{Figure 1}{Figure 2}

The patient was having dark pigmented skin and bilateral pigmentation with poorly defined margins. Black hyperpigmented lesions were present below both eyelids since birth. Keen observation of Surma in both eyelids margin, foreign body sensation and watering in both eyes gives us clue for a possible embedded kohl. The patient was using Surma since 3 years as religious belief. Surma particles were embedded in the upper palpebral conjunctiva and fornices. Kajal (Surma) is a common cosmetic among the Indian people, and its use in pediatric age is very prevalent. The beliefs and practices are related to Muslim religion.

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