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This one-year-old boy is the product of a normal pregnancy and delivery.  The family noted a mass at the junction of the superior and medial orbital rim shortly after birth. It enlarged for a few months and now seems stable.  The mass is soft, non-tender, and seems to be fixed in position. The child is in no distress and appears healthy and had no other skin lesions or pigmented spots.

1.	You did retinoscopy after dilating the eyes with Cyclogyl 1%.  Which of the following would be most likely to represent what you would find with this testing?
	b -- OD +1.00,  OS -2.50 + 3.50 X 135 This mass would push on the eye and create an astigmatism with the steepest curve at 45 degrees.  This type of lesion producing this kind of astigmatism is very amblyopiogenic.  If left untreated, this child will have very poor vision in the left eye.
2.	What is the most likely diagnosis?
	e -- none of the above Sorry for this “trick”.   Being soft pretty much rules out dermoid.  There is no reason to think of neurofibromatosis with a normal exam meaning no café-au-lait spots.  Abscess is a long shot and unlikely and ganglioma is just a “throw in”.
3.	How would you treat this?
	d -- excise it surgically Since the most likely diagnosis is encapsulated hemangioma, excision is the best choice in my opinion. However, before embarking on surgery it would be best to obtain imaging to rule out a meningocele. This would be suspected if there were a bony defect in the area the mass. If surgery were done without imaging, the lesion should be approached carefully.  If pulsation is seen, then a meningocele would be likely and the case would take a different direction.  Unless you were prepared to deal with this, the incision should be closed.  If there is any leakage of cerebrospinal fluid, the defect should be closed with a tapered needle and the patient given a short course of antibiotics.