Periorbital intraosseous hemangiomas are a rare clinical entity that may present with visual or cosmetic disturbances. They may be difficult to distinguish from other bony lesions such as malignant metastases. If the diagnosis of hemangioma can be confidently made in a mildly symptomatic patient, the lesion may be observed. In patients in whom the diagnosis is uncertain or when there is visual compromise such as optic nerve compression, total surgical excision is recommended. Preoperative evaluation with angiography should be strongly considered, particularly if embolization can be accomplished prior to surgery. Even then, the surgeon and the patient must be prepared for the risk of significant hemorrhage.