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A Man With a Large Conjunctival Lesion

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 27-year-old man presented to the clinic for evaluation of a mass in his right eye. He had an unremarkable medical and ocular history and had not sustained any ocular trauma. He described a painless, reddish mass in his lateral conjunctiva, which had been present since birth. He was asymptomatic aside from rare episodes of pink tears in his right eye, and the lesion did not bother him cosmetically. He noted no blurry vision, diplopia, or pain with eye movements. His visual acuity was 20/20 OU, and there was no proptosis, ptosis, or afferent pupillary defect. Extraocular muscle movements were intact, and his intraocular pressure was 15 mm Hg OU. There was no change in lesion size observed with the Valsalva maneuver. A slitlamp examination revealed an 8-mm, round, fluctuant, vascular, multifocal mass involving the bulbar and palpebral conjunctiva near the lateral canthus (Figure). The results of the rest of the examinations, including cornea, anterior chamber, and dilated fundus examinations, were normal in both eyes.

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Superficial conjunctival lymphatic venous malformation

A. Obtain magnetic resonance imaging of the brain and orbits

The patient underwent magnetic resonance imaging of the brain and orbits (choice A), which demonstrated a nonenhancing lobular lesion in the right anterolateral periorbit without any posterior extension. The patient was clinically diagnosed with a superficial conjunctival lymphatic venous malformation, and he elected for observation.

An excisional biopsy of the lesion (choice B) would not be the preferred next step because it is important to define the extent of the lesion prior to surgical intervention. While the patient lacked orbital symptoms and the lesion appeared superficial, lymphatic venous malformations are commonly multifocal and have deep components that must be assessed. Needle drainage of the lesion (choice C) would similarly not be the most appropriate next step without defining the lesion’s extent, and it is associated with a high likelihood of recurrence.1 Systemic propranolol (choice D) would not be the preferred choice because, while propranolol is commonly used to treat capillary hemangiomas in young children and infants, its use in older children and adults with vascular and lymphatic malformations is not well described and may not be as efficacious.2

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Article Information

Corresponding Author: Levi N. Kanu, MD, 1855 W Taylor St, Ste 1.145 (MC 648), Chicago, IL 60612 (levi.kanu@gmail.com).

Published Online: May 9, 2019. doi:10.1001/jamaophthalmol.2019.1130

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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Skalka  HW, Callahan  MA.  Ultrasonically-aided percutaneous orbital aspiration.  Ophthalmic Surg. 1979;10(11):41-43.PubMedGoogle Scholar
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3.
Rootman  J, Hay  E, Graeb  D, Miller  R.  Orbital-adnexal lymphangiomas: a spectrum of hemodynamically isolated vascular hamartomas.  Ophthalmology. 1986;93(12):1558-1570. doi:10.1016/S0161-6420(86)33525-5PubMedGoogle ScholarCrossref
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Smoker  WRK, Gentry  LR, Yee  NK, Reede  DL, Nerad  JA.  Vascular lesions of the orbit: more than meets the eye.  Radiographics. 2008;28(1):185-204. doi:10.1148/rg.281075040PubMedGoogle ScholarCrossref
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Selva  D, Strianese  D, Bonavolonta  G, Rootman  J.  Orbital venous-lymphatic malformations (lymphangiomas) mimicking cavernous hemangiomas.  Am J Ophthalmol. 2001;131(3):364-370. doi:10.1016/S0002-9394(00)00826-6PubMedGoogle ScholarCrossref
6.
Suzuki  Y, Obana  A, Gohto  Y, Miki  T, Otuka  H, Inoue  Y.  Management of orbital lymphangioma using intralesional injection of OK-432.  Br J Ophthalmol. 2000;84(6):614-617. doi:10.1136/bjo.84.6.614PubMedGoogle ScholarCrossref
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Russin  JJ, Rangel-Castilla  L, Kalani  MYS, Spetzler  RF.  Surgical management, outcomes, and recurrence rate of orbital lymphangiomas.  J Clin Neurosci. 2015;22(5):877-882. doi:10.1016/j.jocn.2014.11.002PubMedGoogle ScholarCrossref
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