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Answers: 2005 Series -  March 15, 2005 Lecture 42 of 52  NEXT»

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This 3-month-old girl was noted by the family first to have a flat red lesion involving the face.  This rapidly thickened to appear as seen in these pictures. The family has noted that the infant is having difficulty opening the left eye.  They also report the left eye being more prominant compared to the right eye.

1. 

The lesion can effect the vision with the following mechanisms, EXCEPT:  

 

d -- cataract

The patient has capillary hemangioma. Although potentially the steroid application for the treatment may cause cataract, the lesion itself will not cause cataract. All the other options have been noted to cause amblyopia in a child with capillary hemangiomas. If any of these conditions are found, treatment to prevent amblyopia (secondary to occlusion or anisometropia) or optic neuropathy (secondary to intraorbital lesions pressing on the nerve) should be undertaken.


2.  What is the next best step for this patient?
 

b -- perform MRI of the orbits

Any p
atient with history of "one eye being prominant compared to the fellow eye" demonstrates a sign of exophthalmos.  For this reason, an intraorbital lesion should be suspected. In order to study this, such a patient should be examined with MRI. The treatment should be determined depending on the extension of the lesion. Observation alone is not an option in the case of an enlarging intraorbital lesion.


3.   What is the best initial step for management for this child?
 

c -- systemic steroid administration

The child has capillary hemangioma with intraorbital component.  Also by the mass effect, the patient has difficulty opening the left eye. Observation alone is an option in some cases of capillary hemangioma.  However, with a progressively enlarging intraorbital lesion, simply watching is not the ideal option. Surgical excision is selected for lesions not involving the skin and for those that do not have an intraorbital component. Steroid injection can help the superficial skin lesion, but it would be technically difficult to inject the orbital portion of the lesion, not to mention the increased risk of damaging adjacent structures. Systemic steroid administration would be the safest and effective initial method for this child.  These should be carefully monitored for systemic response.  An expert in pediatrics and/or pediatric enocrinology should be consulted if possible.

 


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