A 3-month-old infant is brought because a red raised mark on the right upper lid, noticed as a faint spot at two weeks, has grown rapidly and now covers the lid, keeping the eye partly closed. The baby is otherwise well and was born at term.
Examination Findings
A bright red, raised, lobulated lesion of the right upper lid — a strawberry haemangioma — causing mechanical ptosis with the visual axis partially covered. The left eye opens normally. Cycloplegic refraction shows induced astigmatism in the right eye. Fundus not yet adequately viewed on the right.
Investigations
Photographic documentation of size for monitoring. Cycloplegic refraction — haemangiomas induce astigmatism and anisometropia. Where the lesion is large or segmental, paediatric assessment for associated syndromes is arranged. The visual axis and refractive state are the ophthalmic priorities.
Questions to Think About
- Why is a benign lump an eye emergency in an infant?
- What are the three mechanisms threatening vision here?
- Why has propranolol changed this disease?
Diagnosis
Periocular infantile haemangioma, right upper lid, with visual-axis occlusion and induced astigmatism.
Reasoning
Reasoning: An infantile haemangioma is benign and usually involutes over years — but in the visual-axis years, ‘usually regresses’ is not reassuring: the lid mass causes deprivation amblyopia by covering the pupil, induces astigmatic anisometropia by pressing on the cornea, and can cause strabismic amblyopia. Three simultaneous amblyopia mechanisms in a 3-month-old constitute an eye emergency measured in weeks. Diagnosis: periocular infantile haemangioma with visual-axis occlusion and induced astigmatism. Management: typical management includes urgent referral to a paediatric ophthalmology/dermatology team, where systemic propranolol — which dramatically shrinks these lesions — is started under paediatric supervision with cardiac screening per protocol; patching and glasses treat the amblyopia in parallel. The parents are told the mark itself will likely fade over years, but the vision work cannot wait for that.
Differential Diagnosis
- Vascular malformation (port-wine stain) — ruled out: flat, present at birth, does not proliferate and involute.
- Rhabdomyosarcoma — ruled out: the classic bright-red proliferating course with a benign appearance; any atypical lesion is biopsied.
- Congenital ptosis — the lid droop is mechanical from the mass, not levator failure.
Management
Typical management includes urgent multidisciplinary referral, systemic propranolol under paediatric supervision where indicated (with pre-treatment cardiac assessment per local protocol), concurrent amblyopia therapy (refractive correction, patching), and photographic monitoring of involution. Large segmental facial lesions prompt assessment for associated syndromes. Long-term follow-up covers refractive development and any residual lid changes.
Key Learning Points
- Infantile haemangioma: appears after birth, proliferates rapidly, then involutes — timing is the diagnosis.
- Near the eye it threatens vision three ways: occlusion, induced astigmatism, strabismus.
- Propranolol under paediatric supervision has transformed management.
- Treat the amblyopia in parallel — the lump shrinking does not automatically restore vision.
Red Flags
- A periocular haemangioma covering the visual axis — amblyopia emergency; refer urgently.
- Rapid growth phase in the first months — the window when vision is most threatened.
- Large segmental facial haemangioma — assess for associated syndromic features.
Educational content only — not medical advice. Clinical decisions must be made by a qualified professional for the individual patient.