Acquired conjunctival capillary hemangioma in an older adult with concomitant ipsilateral superficial venous dilatation: a case report

Acquired conjunctival capillary hemangioma is an uncommon vascular lesion in adults and may be mistaken for a conjunctival cyst. Its anterior segment optical coherence tomography (AS-OCT) features have not been well characterized. We report the AS-OCT, orbital imaging, and clinicopathologic findings of this lesion in an older adult in whom MRI also demonstrated ipsilateral superficial venous dilatation. A 60-year-old man presented with a chronic vascularized bulbar conjunctival lesion in the left eye that had not improved after two needle punctures and topical steroid therapy at another hospital. Examination revealed an ill-defined 4 × 5 mm temporal bulbar subconjunctival lesion with dilated conjunctival vessels, yellow-white subepithelial material, and poor mobility. During follow-up, the lesion gradually enlarged, with an increase in the yellow-white subepithelial material, and foreign-body sensation worsened. Orbital MRI demonstrated dilatation of the ipsilateral supraorbital and middle temporal veins without an intraorbital or intracranial mass lesion, and contrast-enhanced magnetic resonance angiography showed no evidence of arteriovenous shunting or a high-flow vascular malformation. Preoperative AS-OCT demonstrated a solid, heterogeneously hyperreflective subepithelial lesion with multiple internal hyporeflective spaces, inconsistent with a simple conjunctival cyst. Excisional biopsy was performed for diagnosis and treatment. Histopathology showed subepithelial proliferation of thin-walled CD34-positive vascular channels with focal D2-40-positive lymphatic channels, consistent with conjunctival capillary hemangioma. The postoperative course was uneventful, with no clinical recurrence through the final follow-up in February 2025. Acquired conjunctival capillary hemangioma should be considered in older adults with a chronic unilateral vascularized bulbar conjunctival lesion. AS-OCT may help distinguish this entity from a conjunctival cyst and support diagnostic reconsideration and excisional biopsy. When superficial venous dilatation is identified on imaging, orbital evaluation may be warranted to exclude other etiologies; however, a causal relationship with the conjunctival lesion cannot be established from a single case.