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PHOTO ESSAY
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 184-185

Cavernous hemangioma of the conjunctiva and its ultrasound biomicroscopic features


1 Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Pathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission26-Jun-2020
Date of Acceptance02-Oct-2020
Date of Web Publication01-Apr-2021

Correspondence Address:
Dr. Jagat Ram
Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2097_20

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  Abstract 


Keywords: Cavernous hemangioma, conjunctiva, propranolol, ultrasound biomicroscopy, Valsalva manoeuvre


How to cite this article:
Balamurugan R, Gupta PC, Ramanadhane R, Geethanjali G, Rastogi P, Ram J. Cavernous hemangioma of the conjunctiva and its ultrasound biomicroscopic features. Indian J Ophthalmol Case Rep 2021;1:184-5

How to cite this URL:
Balamurugan R, Gupta PC, Ramanadhane R, Geethanjali G, Rastogi P, Ram J. Cavernous hemangioma of the conjunctiva and its ultrasound biomicroscopic features. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 29];1:184-5. Available from: https://www.ijoreports.in/text.asp?2021/1/2/184/312356




  Case Report Top


A 47-year-old female presented with a reddish-purple elevated mass in the right eye for the past 2 years. The onset of the mass was insidious and gradually increasing in size. There was no history of any trauma or any previous ocular surgery. No evidence of mucosal or cutaneous mass lesion on systemic examination was present.

Her best-corrected visual acuity was 6/9 bilaterally. Slit-lamp examination of the right eye revealed a 6 mm × 5 mm partially mobile, cystic, bulbar conjunctival lesion in the nasal part of the conjunctiva with well-defined borders and overlying tortuous vessels as shown in [Figure 1]a. There were no visible pulsations or an increase in the size of the mass on performing the Valsalva manoeuvre. Rest of the ocular evaluation as well as examination of the other eye was within normal limits. Based on history and clinical examination, a diagnosis of benign vascular tumor was made.
Figure 1: (a) It shows the cavernous hemangioma of the bulbar conjunctiva. (b) It shows the post excision photo of the lesion at 1-month follow-up

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Ultrasound biomicroscopy (UBM) at 50 MHz frequency was carried out in supine position with the right eye looking laterally and the eye immersed in normal saline-filled watercap and the probe being kept parallel to the lesion.[1] The scan [Figure 2]a and [Figure 2]b demonstrated multiple cystic spaces with moderate to high internal echogenicity with a visible horizontal level suggestive of blood-filled cystic cavity. The mass had well-defined margins with absence of invasion to the surrounding tissues of cornea and sclera.
Figure 2: (a and b) They show the ultrasound biomicroscopic image with gain being kept at 100 dB with the probe being kept abutting the mass lesion parallel to it describing normal scleral texture and a well-circumscribed conjunctival mass with multiple intralesional cystic cavities filled with the moderate to high intensity echoes suggestive of blood-filled cyst

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The mass was excised with amniotic membrane transplantation. Histopathology [Figure 3]a and [Figure 3]b revealed dilated vascular channels arranged back to back in the subepithelial conjunctival stroma. These vascular channels were thin walled and were lined by flattened endothelial cells confirming the diagnosis of cavernous hemangioma. The patient was followed up for 1 year and no recurrence was noted [Figure 1]b.
Figure 3: (a) It shows surface conjunctival lining with large blood-filled cavernous spaces underneath (H and E, 4× magnification). (b) These blood-filled spaces are lined by a single layer of endothelial lining (H and E, 40× magnification)

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  Discussion Top


Hemangioma is an example of a hamartoma. It consists of irregular thick and thin-walled sinusoidal vascular channels.[2],[3] Cavernous hemangiomas usually present as benign intraorbital tumors in adults; however, the conjunctival types are very rare.[4],[5] Based on the retrospective case series by Shields et al. on clinical features of vascular tumors of the conjunctiva done among 140 patients, the incidence of cavernous hemangioma was found to be 0.2%.[5] It is seen mostly in adults between the fourth and fifth decades of life with higher female preponderance.[6] A prospective study by Buchwald et al. to compare the value of UBM and anterior segment optical coherence tomography (AS-OCT) in the diagnosis of conjunctival lesions revealed that AS-OCT shows very small cystic structures, while UBM is better for better assessment of tumor margin assessment.[7] There have been isolated case reports of resolution of these lesions with timolol eye drops, similar to the treatment of cutaneous capillary hemangioma in infants with propranolol.[8] However, most patients do well with excisional biopsy and do not require further therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vizvari E, Skribek A, Polgar N, Voros A, Sziklai P, Toth-Molnar E. Conjunctival melanocytic naevus: Diagnostic value of anterior segment optical coherence tomography and ultrasound biomicroscopy. PLoS One 2018;13:e0192908.  Back to cited text no. 1
    
2.
Shields CL, Shields JA. Tumors of the conjunctiva and cornea. Surv Ophthalmol 2004;49:3-24.  Back to cited text no. 2
    
3.
Rao MR, Patankar VL, Reddy V. Cavernous haemangioma of conjunctiva (a case report). Indian J Ophthalmol 1989;37:37-8.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Mukherjee B, Moosa S, Rajagopal R. Cavernous hemangioma of the conjunctiva. Indian J Ophthalmol 2019;67:2061.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Shields JA, Mashayekhi A, Kligman BE, Kunz WB, Criss J, Eagle RC Jr, et al. Vascular tumors of the conjunctiva in 140 cases. Ophthalmology 2011;118:1747-53.  Back to cited text no. 5
    
6.
Kodavoor SK, Sarvate N. Management of isolated subconjunctival hemangioma masquerading as ocular surface squamous neoplasia. TNOA J Ophthalmic Sci Res 2017;55:310-2.  Back to cited text no. 6
  [Full text]  
7.
Buchwald HJ, Muller A, Kampmeier J, Lang GK. Optical coherence tomography versus ultrasound biomicroscopy of conjunctival and eyelid lesions. Klin Monbl Augenheilkd 2003;220:822-9.  Back to cited text no. 7
    
8.
Chang T, Estes R. Beta blocker treatment of infantile conjunctival hemangiomas—Observations from 2 cases. J AAPOS 2014;18:80-2.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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