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[page 32] [Eye Reports 2011; 1:e10]

Conjunctival blue nevus
Joseph J. Chen, Seongmu Lee, 
Michael T. Yen
Cullen Eye Institute, Department of
Ophthalmology, Baylor College of
Medicine, Houston, TX, USA

Abstract 

The authors report a case of a conjunctival
blue nevus and review the literature pertain-
ing to these pigmented lesions in this location,
describing clinical and histological report of a
patient with a blue nevus of the palpebral con-
junctiva with a literature review. A 64-year-old
white female was evaluated for a darkening
pigmented lesion of the left lower palpebral
conjunctiva. Examination revealed a 3 mm x
6mm blue-black lesion with sharply demarcat-
ed edges and an irregular border. Histopa -
thology showed plump spindle-shaped, pig-
mented melanocytic cells revealing a branch-
ing network of dendritic processes with small,
elongated, and hyperchromatic nuclei consis-
tent with a common blue nevus. No recurrence
was noted at 9-month follow-up. Blue nevi of
the conjunctiva are lesions that have a low risk
for malignant transformation but can appear
clinically similar to primary acquired
melanosis or melanoma. Blue nevi of the con-
junctiva are rare and represent 0.5%-3.0% of
pigmented conjunctival lesions. There was one
reported case in a literature search of a malig-
nant melanoma arising from a conjunctival
cellular blue nevus. Treatment is complete
wide excisional biopsy.

Introduction

Blue nevi are skin lesions containing
melanocytic proliferations which can present
in a variety of locations, most commonly in the
dorsum of the hands and feet, the scalp, and
the sacrococcygeal regions.1 Blue nevi also
rarely present in mucosal membranes, such as
the mouth, nose, uterus, vagina, endometri-
um, prostate, bronchus, and esophagus.2 We
present a case of a rare presentation of a com-
mon blue nevus in the palpebral conjunctiva.

Case Report

A 64-year-old white female was referred for
a darkening pigmented lesion noted on her left
lower palpebral conjunctiva. The patient
reported that the lesion had been present for

more than 10 years and while she had not
noticed any growth in the size of the lesion, it
had become darker in appearance. She denied
any family history of skin malignancies or ocu-
lar lesions. She had no history of previous pig-
mented lesions or history of malignancy, and
review of systems was noncontributory.
On slit lamp exam, a flat hyperpigmented

lesion with irregular borders was noted in the
inferior palpebral conjunctiva on the right eye
measuring 3.1 mm vertically and 6.2 mm hori-
zontally (Figure 1). The remainder of the ocu-
lar exam was unremarkable. The lesion was
fully excised and sent for histopathologic
analysis. 
Histologically, there was mid to deep dermal

proliferation of pigmented dermal melanocytes
with no junctional component and no involve-
ment of the epidermal layers (Figure 2). On
higher magnification, there were pigmented
spindle-shaped dendritic melanocytes reveal-
ing a branching network of dendritic processes
with small, elongated, and hyperchromatic
nuclei (Figure 3). The dendritic cells did not
display any cytologic atypia or mitotic figures.
A diagnosis of common blue nevus was made.
At 9 month follow-up, the patient displayed no
evidence of recurrence.

Discussion

Blue nevi were first described by Jadassohn-
Tieche in 1906 with a distinction made by
Allen and Spitz in 1953 dividing blue nevi into
the classically described categories of common
blue nevus and cellular blue nevus.1-3 In cur-
rent literature, the common blue nevus type
has been further subtyped to include common
blue nevus, combined blue nevus, sclerosing
(desmoplastic) blue nevus, hypomelanotic/
amelanotic blue nevus, and epithelioid blue
nevus of Carney Complex/pigmented epithe-
lioid melanocytoma. The cellular blue nevus
has been further subtyped into cellular blue
nevus, amelanotic cellular blue nevus, atypical
cellular blue nevus, and malignant blue nevus.2

Common blue nevi are distinguished histo-
logically by characteristic variably pigmented
spindle-shaped dendritic melanocytes in the
mid to deep dermis which do not have a junc-
tional component and which do not display any
significant cytologic atypia. Cellular blue nevi
are distinguished from common blue nevi in
that they usually present as a pigmented
biphasic tumor with a classic blue nevus com-
ponent and a component of distinct cellular
areas of spindled to oval melanocytes with
clear cytoplasm. Both common and cellular
blue nevi can present at any age, although typ-
ically present in the third or fourth decade and
most commonly are found in the sacrococ-
cygeal region, scalp, face, and dorsal areas of

the extremities.1 A subtype of cellular blue
nevus has been described as malignant blue
nevus, which has features of cellular blue
nevus but can metastasize and result in death.
Malignant blue nevi can arise from prior biop-
sy or excision sites of blue nevi or can arise de
novo.2 Histopa thologically, malignant blue nevi
appear similar to cellular blue nevi with a
biphasic architecture but have severely atypi-
cal cytologic features.4 Malignant blue nevi
have a poor prognosis, with a high rate of
recurrence and metastasis. In a case series of
12 patients with melanoma arising from blue
nevus in the skin, 10 of 12 (83%) patients
developed metastases over a mean period of 40
months.5 Some studies have shown that
immunohistochemistry may be of benefit,
showing that malignant blue nevi show
increased Ki-67 expression and may lose HMB-
45 labeling.6 Recently, Zembowicz et al. have
suggested that the Gnaq and Gna11 proteins of
the G-protein alpha subunits involved in sig-
naling by G-protein coupled receptors are
important for controlling early dermal
melanoblast proliferation, citing that there is a
permanent increase in dermal melanoblast
numbers with activating mutations in Gnaq
and Gna11, and also that somatic mutations in
the GNAQ gene have been identified in 83% of
cases of blue nevi, 50% of malignant blue nevi,
and 46% of uveal melanoma.2

The pathogenesis of blue nevi has not been
well established, but most currently, the pre-
vailing theory postulates that dermal
melanocytes are arrested during embryologic
migration from the neural crest to the epider-

Eye Reports 2011; volume 1:e10

Correspondence: Michael T. Yen, Cullen Eye
Institute, Department of Ophthalmology, Baylor
College of Medicine, 6565 Fannin NC-205,
Houston, TX 77030, USA. 
Tel: +1.713.798-3231 - Fax: +1.713.798.8739.
E-mail: myen@bcm.tmc.edu

Key words: conjunctiva, blue nevus, melanocytic
proliferation.

Acknowledgements: supported in part by an unre-
stricted educational grant from Research to
Prevent Blindness, Inc. (New York, NY).

Conflict of interest: the authors report no con-
flicts of interest. 

Received for publication: 29 June 2011.
Accepted for publication: 11 September 2011.

This work is licensed under a Creative Commons
Attribution NonCommercial 3.0 License (CC BY-
NC 3.0).

©Copyright J.J. Chen et al., 2011
Licensee PAGEPress, Italy
Eye Reports 2011; 1:e10
doi:10.4081/eye.2011.e10

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[Eye Reports 2011; 1:e10] [page 33]

mis.2 This theory is supported by the fact that
melanocytes, after population of the dermis
from 10 weeks of gestation, will disappear at
the end of gestation except in the presacral
area, head and neck area, and dorsal areas of
the distal extremities, which are also the most
common sites of presentation for blue nevi in
the skin.1

Blue nevi rarely occur in the conjunctiva,
with only 22 reported cases of conjunctival blue
nevi in the literature to date. There have been
four large case series of pigmented conjuncti-
val lesions, which noted blue nevi. In the
largest series of 418 conjunctival nevi, Shields,
et al. reported that 4 of the cases conjunctival
nevi were histologically confirmed as blue
nevi. Of these 4 cases, 2 were located in the
bulbar conjunctiva, one in the tarsal conjuncti-
va, and one in the fornix. All were brown in
color, none had cysts, none had feeder vessels,
and one has intrinsic vessels. One of the cases
of blue nevus developed malignant melanoma;
this case was one of the only 3 patients out of
410 patients in the series who developed
malignant melanoma.7 Grossniklaus, et al.
reported five out of 317 (1.5%) pigmented con-
junctival lesions to be blue nevi in adults.8 Out
of a series of 71 pigmented conjunctival
lesions in children reported by McDonnell, et
al., only one (1.6%) was found to be a blue
nevus.9 Of the conjunctival blue nevi which
report histopathologic analysis, there were 6
common blue nevi, including the blue nevus in
this report, and 5 cellular blue nevi.10-12 In addi-
tion to the one case from the Shield, et al.
series in which malignant melanoma devel-
oped,7 there was only one case of malignant
transformation of a blue nevus reported, which
was described histologically as a cellular blue
nevus that appeared on exam as primary
acquired melanosis and reported no recur-
rence after excision at 7 year follow-up.11 It is
uncertain whether these two reports represent
the same patient or two different patients, as
the two reports are from the same institution
and share some authors.
In summary, blue nevi are distinct

melanocytic neoplasms that are commonly
found in the skin but rarely occur in mucosal
membranes, including the conjunctiva.
Conjunctival blue nevi, particularly the cellular
blue nevus subtype, have a rare potential for

malignant transformation and have the poten-
tial to recur after excision. Because of this low
potential for malignant transformation, treat-
ment is wide local excisional biopsy with sur-
veillance.

References

1. Rodriguez HA, Ackerman LV. Cellular blue
nevus: clinicopathologic study of forty-five
cases. Cancer 1968;21:393-405.

2. Zembowicz A, Pushkar AD. Blue nevi and
variants: an update. Arch Pathol Lab Med
2011;135:327-36.

3. Allen AC, Spitz S. Malignant melanoma; a
clinicopathological analysis of the criteria
for diagnosis and prognosis. Cancer 1953;
6:1-45.

4. Duteille F, Duport G, Larregue M, et al.
Malignant blue nevus: three new cases
and a review of the literature. Ann Plast
Surg 1998;41:674-8.

5. Connelly J. Smith JL Jr. Malignant blue
nevus. Cancer 1991;67:2653-7.

6. Prieto VG, Shea CR. Use of immunohisto-
chemistry in melanocytic lesions. J Cutan
Pathol 2008;35 Suppl 2:1-10. 

7. Shields CL, Fasiuddin AF, Mashayekhi A,
Shields JA. Conjunctival nevi: clinical fea-
tures and natural course in 410 consecu-
tive patients. Arch Ophthalmol 2004;122:
167-75.

8. Grossniklaus HE, Green WR, Luckenbach
M, Chan CC. Conjunctival lesions in
adults: a clinical and histopathologic
review. Cornea 1987;6:78-116.

9. McDonnell JM, Carpenter JD, Jacobs P, et
al. Conjunctival melanocytic lesions in
children. Ophthalmology 1989;96:986-93.

10. Alkatan HM, Arfaj KM, Maktabi A.
Conjunctival nevi: clinical and histopatho-
logic features in a Saudi population. Ann
Saudi Med 2010;30:306-12.

11. Demirci H, Shields CL, Shields JA, Eagle
RC Jr. Malignant melanoma arising from
unusual conjunctival blue nevus. Arch
Ophthalmol 2000;118:1581-4.

12. Leopold JG, Richards DB. The interrela-
tionship of blue and common naevi. J
Pathol Bacteriol 1968;95:37-46.

Case Report

Figure 1. External photograph shows a flat,
hyperpigmented blue-black lesion with
irregular borders deep in the stroma with
no apparent vascularity.

Figure 2. Conjunctival blue nevus. Heavily
pigmented dendritic melanocytes located
in the substantia propria with normal con-
junctival epithelium and no evidence of
acquired melanosis (hematoxylin-eosin,
original magnification x 40).

Figure 3. Plump, heavily pigmented spin-
dle-shaped melanocytes with no junctional
activity and no involvement of the conjunc-
tival epithelium with small, elongated, and
hyperchromatic nuclei (hematoxylin-eosin,
original magnification x 200).

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