Photo Essay
A c q u i r e d c o n j u n c t i va l s e s s i l e
hemangioma
Devashish Dubey, Rajesh Ramanjulu,
Mahesh P Shanmugam, Divyansh K Mishra
Key words: Acquired sessile conjunctiva, conjunctival
hemangioma, conjunctival vascular tumor
A 63-year-old male came with complaints of a small red mass
overlying the left eye bulbar conjunctiva. On examination,
b
Figure 1: Anterior segment picture showing a 3‑  ×2‑mm vascular
network with interlacing blood vessels over the bulbar conjunctiva with
dilated feeder vessels adjacent to the limbus (a). Anterior segment
optical coherence tomography (AS‑OCT) showed an epithelium
lined hyper‑reflective lesion with internal hypo‑reflective spaces
corresponding to the vascular lumen with posterior shadowing and
scleral compression without scleral invasion (b)
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DOI:
10.4103/ijo.IJO_1978_19
PMID:
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Sankara Eye Hospital, Bengaluru, Karnataka, India
Correspondence to: Dr.  Rajesh Ramanjulu, Sankara Eye Hospital,
Bengaluru, Karnataka, India. E‑mail: drragraj@gmail.com
Received: 27-Oct-2019 Revision: 26-Dec-2019
Accepted: 02-Jan-2020 Published: 25-May-2020
© 2020 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow
a 3 × 2 mm network of flat, interlacing, slightly dilated
conjunctival blood vessel was seen adjacent to the limbus
[Fig. 1a]. The feeder vessels could be easily localized. AS-
OCT done through the lesion showed an epithelium lined
hyper-reflective lesion with internal hypo-reflective spaces
corresponding to the vascular lumen [Fig. 1b]. An external
OCT-A was done, which showed a well-delineated vascular
lesion and its feeder vessel with underlying deep conjunctival
vessels [Fig. 2a and b]. The cross-sectional OCT-A showed an
area of localized hyper-flow corresponding to the area of the
lesion [Fig. 2c].
Upon probing, the patient admitted to the persistence of
the docile lesion since the past two years. He was otherwise
asymptomatic. The lesion was not excised and sent for
histopathological confirmation as it was asymptomatic and it
had typical features of a conjunctival hemangioma.
Acquired conjunctival hemangiomas are extremely
rare; vascular lesions first described clinically in a series of
10 patients by Shields et al.[1] They described it to be an unusual
conjunctival vascular lesion in adults having no systemic or
ocular associations. Histopathological analysis was done in one
patient who elected to have the lesion removed, demonstrating
two layers of enlarged blood vessels beneath the conjunctival
epithelium.
a b
c
Figure 2: Enface OCT‑A showing the superficial well‑demarcated
vascular lesion with its feeder vessel (a) along with deep conjunctival
vessels (b). Cross‑sectional OCT‑A showing the localized subepithelial
vascular hyper‑flow corresponding to the area of the lesion (c)
This is an open access journal, and articles are distributed under the terms of
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which allows others to remix, tweak, and build upon the work non‑commercially,
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For reprints contact: reprints@medknow.com
Cite this article as: Dubey D, Ramanjulu R, Shanmugam MP, Mishra DK.
Acquired conjunctival sessile hemangioma. Indian J Ophthalmol
2020;68:1155-6.
1156 Indian Journal of Ophthalmology Volume 68 Issue 6

Usually, these lesions require no treatment since most
remain stable without any complications. Few of these lesions
have been found to regress spontaneously or after use of topical
timolol.[2] The ones rarely showing progressive growth can be
safely excised.[3]
Conjunctival OCT‑A can noninvasively depict the lesion
vascularity and all layers of flow accurately and can be used
as an alternate imaging modality to fluorescein angiography.[4]
This essay highlights the various imaging signatures of this
rare conjunctival lesion.
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
1. Shields  JA, Kligman  BE, Mashayekhi A, Shields  CL. Acquired
sessile hemangioma of the conjunctiva: A report of 10 cases. Am J
Ophthalmol 2011;152:55‑9.e1.
2. Lubahn JG, Lee RK, Karp CL. Resolution of conjunctival sessile
hemangioma with topical timolol. Cornea 2014;33:99‑100.
3. Nattis A, Perry HD, Rosenberg ED, Cocker R. Conjunctival capillary
hemangioma. Cureus 2017;9:e1892.
4. Chien  JL, Sioufi  K, Shields  CL. Optical coherence tomography
a n g i o g ra p h y o f co n j u n ct i va l ra ce mo s e h e m an g i om a.
Ophthalmology 2017;124:449.

Herpetic stromal keratitis after Optical Coherence Tomography  (AS‑OCT) showed hyper
reflectivity involving almost full thickness of stroma without
collagen cross‑linking for keratoconus: the involvement of other corneal layers  [Fig.  2a]. Corneal
A unique presentation fluorescein angiography  (FA) was performed by injecting
5  ml of 10% fluorescein intravenously, which showed an
arborizing network of vessels with subsequent leakage [Fig. 3].
Akhil Bevara, Sudhakar Potti

Key words: Collagen cross‑linking, corneal fluorescein

angiography, deep corneal neovascularization, herpetic stromal
keratitis, keratoconus

A 22‑year‑old male who underwent collagen cross‑linking

(CXL) in both eyes elsewhere 3  years ago for keratoconus
presented with symptomatic blurring of vision and redness in
the left eye. On examination, the best‑corrected visual acuity
(BCVA) was 20/80, N6 in the left eye. Cornea showed a 4 × 3 mm
deep corneal neovascularization in an arborizing pattern and
stromal edema with feeder vessels from 5 o’ clock limbus
[Fig. 1]. Corneal sensations were reduced. Anterior segment

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DOI: Figure 1: Cornea of left eye showing 4  ×  3  mm deep corneal

10.4103/ijo.IJO_1525_19 neovascularization with feeder vessels from 5 o’clock limbus

PMID:
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Sankara Eye Hospital, Guntur, Andhra Pradesh, India
Correspondence to: Dr.  Akhil Bevara, Sankara Eye Hospital,
Guntur ‑Vijayawada Expressway, Pedakakani, Guntur - 522 509,
Andhra Pradesh , India. E‑mail: bevaraakhil@gmail.com
Received: 20-Aug-2019 Revision: 28-Nov-2019
Accepted: 25-Jan-2020 Published: 25-May-2020
This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are licensed under
the identical terms.
For reprints contact: reprints@medknow.com
Cite this article as: Bevara A, Potti S. Herpetic stromal keratitis after collagen
cross-linking for keratoconus: A unique presentation. Indian J Ophthalmol
2020;68:1156-8.