Visual development in infants: visual complications of periocular haemangiomas

Ocular and orbital tumors in childhood

Pediatric tumors of the eye and orbit can be benign or malignant as well as congenital or acquired and are usually distinctively different than those seen in adults. Although most of these neoplasms are benign (eg, dermoid cyst, chalazion, molluscum), their location near and within a vital organ can result in serious dermatologic and ophthalmologic sequelae. Lesions discussed include vascular lesions, retinoblastomas (the most common primary pediatric intraocular malignancy), rhabdomyosarcoma (the most common primary pediatric orbital malignancy), Langerhans cell histiocytosis, and metastatic lesions to the orbit (neuroblastoma, Ewing sarcoma). Although cysts and ocular melanoma can occur within the pediatric population, these conditions are covered in other contributions in this issue of Clinics in Dermatology.

Advantages of Early Surgical Management of Periorbital Infantile Hemangiomas

Background: Early evaluation and treatment of periorbital infantile hemangiomas (POIH) were associated with lower rates of ophthalmological complications. Objective: To evaluate age and characteristics associated with improved anisometropic astigmatism (anisoastigmatism) and eye symmetry measured by diopters and a 5-point scale, respectively, in patients with POIH treated with surgical excision. Methods: A retrospective study was performed on patients with POIH. Patient characteristics and eye symmetry were analyzed between patients with resolved and unresolved anisoastigmatism after surgery. Statistical analyses included the Mann-Whitney U tests, chi-square tests, and linear regression models. Results: In total, 54 patients were included (male: 20, female: 34). Upper medial eyelid was the most commonly affected site (resolved: 45%, unresolved: 43%), followed by upper lateral and upper central. Fifty-six percent (31/55) had postoperative resolution of anisoastigmatism, whereas 44% (24/55) did not. Earlier surgical evaluation (median: 4.5 vs. 6.0 months, p = 0.047) and excision (median: 5.0 vs. 12.0 months, p = 0.005) were associated with reversible anisoastigmatism. Good and suboptimal eye symmetry were not associated with earlier surgical excision (median: 6 vs. 6.5 months, p = 0.87). Follow-up ranged from 1 month to 12 years. Conclusion: Earlier surgical excision was associated with reversing anisoastigmatism but was not significant for improving eye symmetry.

Distribution and Clinical Characteristics of Periorbital Infantile Hemangiomas

Background: Periorbital infantile hemangiomas (POIHs) are associated with a high incidence of visual complications. Objective(s): To analyze the sites of predilection of POIHs and to determine whether certain sites require earlier intervention due to their higher rate of visual complications. Methods: A retrospective case series study was conducted on patients from two tertiary care centers for 25 years. The location of POIHs was determined from clinical photographs, medical records, and radiological studies. The presence or absence of anisometropic astigmatism (anisoastigmatism) and amblyopia was recorded. Data were analyzed using a chi-square test. Results: There were 486 patients, of which 302 patients had ophthalmology evaluations and 245 patients had refractive error data. At presentation, 10% of patients already had amblyopia and 44% had anisoastigmatism. Medial eyelid lesions had the highest risk of developing anisoastigmatism (anisoastigmatism correlates with eyelid position, p = 0.0001). Segmental and upper medial lesions had the highest risk of amblyopia at initial evaluation. Conclusion: The site of POIH is an important indicator for developing clinically significant anisoastigmatism and amblyopia, underlining the need for early ophthalmologic assessment and management.

OUP accepted manuscript

Infrared thermography is a useful adjunct for the clinical monitoring of infantile hemangioma (IH) activity with or without treatment. There is a dearth or reporting on the ideal tissue for standardizing temperature readings from IH. This case illustrates the use of mean medial canthal temperatures and the differential hemangioma temperatures for monitoring of facial IH.

Update on infantile hemangioma

The International Society for the Study of Vascular Anomalies classifies vascular anomalies into vascular tumors and vascular malformations. Vascular tumors are neoplasms of endothelial cells, among which infantile hemangiomas (IHs) are the most common, occurring in 5%-10% of infants. Glucose transporter-1 protein expression in IHs differs from that of other vascular tumors or vascular malformations. IHs are not present at birth but are usually diagnosed at 1 week to 1 month of age, rapidly proliferate between 1 and 3 months of age, mostly complete proliferation by 5 months of age, and then slowly involute to the adipose or fibrous tissue. Approximately 10% of IH cases require early treatment. The 2019 American Academy of Pediatrics clinical practice guideline for the management of IHs recommends that primary care clinicians frequently monitor infants with IHs, educate the parents about the clinical course, and refer infants with high-risk IH to IH specialists ideally at 1 month of age. High-risk IHs include those with life-threatening complications, functional impairment, ulceration, associated structural anomalies, or disfigurement. In Korea, IHs are usually treated by pediatric hematology-oncologists with the cooperation of pediatric cardiologists, radiologists, dermatologists, and plastic surgeons. Oral propranolol, a nonselective beta-adrenergic antagonist, is the first-line treatment for IHs at a dosage of 2-3 mg/kg/day divided into 2 daily doses maintained for at least 6 months and often continuing until 12 months of age. Topical timolol maleate solution, a topical nonselective beta-blocker, may be used for small superficial type IHs at a dosage of 1-2 drops of 0.5% gel-forming ophthalmic solution applied twice daily. Pulse-dye laser therapy or surgery is useful for the treatment of residual skin changes after IH involution.

Isolated deep orbital hemangioma treated successfully with oral propranolol in a 2-month-old infant: Case report with literature review

Purpose

Infantile hemangiomas (IH) are the most common benign vascular tumors of infancy. Ocular complications due to orbital IH include strabismal, deprivational, or anisometropic astigmatism, and visual loss secondary to amblyopia.

Observations

We report a case of a two-month-old female infant with a severe deep orbital IH. The diagnosis was established by clinical examination and magnetic resonance imaging (MRI). The patient was treated with oral propranolol for six months. Complete tumor regression was observed clinically and by MRI following the treatment. The patient showed no adverse effects or tumor recurrence at the 14-month follow-up.

Conclusions and Importance

Despite its benign nature, periorbital IH requires a rapid diagnosis and prompt treatment to prevent vision loss, particularly in infants. Our case confirms that oral propranolol may be regarded as a safe drug for periorbital IH with an excellent outcome.

Current treatment and management of infantile hemangiomas

Infantile hemangiomas, otherwise known as infantile capillary hemangiomas, strawberry hemangiomas, or strawberry nevi, are nonmalignant vascular tumors that commonly affect children. The natural disease course typically involves growth for up to a year, followed by regression without treatment over a period of years with no cosmetic or functional sequelae. Less commonly, however, infantile hemangiomas can become a threat to vision or even life depending on location and size of the lesion. In addition, infantile hemangiomas, particularly those involving the face, may be disfiguring and result in lifelong sequelae. β-blockers have become a mainstay of therapy given their relatively low-risk profile and efficacy. Other treatment modalities previously described in the literature include corticosteroids (both intralesional and systemic), imiquimod, vincristine, bleomycin A5, and interferon α. More recently, angiotensin-converting enzyme inhibitors such as captopril have been used. Laser therapy and, less commonly, surgical excision are also available treatment options. We review current recommended management and treatment of capillary hemangiomas and discuss the benefits and risks of all previously reported treatment modalities.

Clinical Practice Guideline for the Management of Infantile Hemangiomas

Infantile hemangiomas (IHs) occur in as many as 5% of infants, making them the most common benign tumor of infancy. Most IHs are small, innocuous, self-resolving, and require no treatment. However, because of their size or location, a significant minority of IHs are potentially problematic. These include IHs that may cause permanent scarring and disfigurement (eg, facial IHs), hepatic or airway IHs, and IHs with the potential for functional impairment (eg, periorbital IHs), ulceration (that may cause pain or scarring), and associated underlying abnormalities (eg, intracranial and aortic arch vascular abnormalities accompanying a large facial IH). This clinical practice guideline for the management of IHs emphasizes several key concepts. It defines those IHs that are potentially higher risk and should prompt concern, and emphasizes increased vigilance, consideration of active treatment and, when appropriate, specialty consultation. It discusses the specific growth characteristics of IHs, that is, that the most rapid and significant growth occurs between 1 and 3 months of age and that growth is completed by 5 months of age in most cases. Because many IHs leave behind permanent skin changes, there is a window of opportunity to treat higher-risk IHs and optimize outcomes. Early intervention and/or referral (ideally by 1 month of age) is recommended for infants who have potentially problematic IHs. When systemic treatment is indicated, propranolol is the drug of choice at a dose of 2 to 3 mg/kg per day. Treatment typically is continued for at least 6 months and often is maintained until 12 months of age (occasionally longer). Topical timolol may be used to treat select small, thin, superficial IHs. Surgery and/or laser treatment are most useful for the treatment of residual skin changes after involution and, less commonly, may be considered earlier to treat some IHs.

Risk factors for ocular complications in periocular infantile hemangiomas

BACKGROUND/OBJECTIVES

Infantile hemangiomas are the most common benign tumors of childhood. Although some children with periocular infantile hemangiomas do not require treatment, these lesions may result in amblyopia and visual impairment if not properly treated. We have attempted to characterize clinical features of periocular infantile hemangiomas that predict negative ocular outcomes and thus require prompt referral to an ophthalmologist and initiation of therapy.

METHODS

This study included children with periocular infantile hemangiomas consecutively seen at Ann & Robert H. Lurie Children's Hospital of Chicago from January 1994 through December 2014. Only patients evaluated by both a dermatologist and an ophthalmologist were included. Medical records of patients who met inclusion criteria were reviewed. Ocular findings were reviewed for the presence of ptosis, refractive errors, strabismus, proptosis, and amblyopia.

RESULTS

Ninety-six patients (74% female, median age of onset 0.48 months) were included. Periocular infantile hemangiomas larger than 1 cm in diameter, with a deep component, and with involvement of the upper eyelid were significantly associated with astigmatism (P = .002, P = .02, and P = .003, respectively) and amblyopia (P = .002, P = .02, and P = .04, respectively). Using logistic regression, diameter greater than 1 cm (odds ratio = 14.13, P = .01) and amblyopia (odds ratio = 21.00, P = .04) were the strongest predictors of astigmatism. Lower lid and medial and lateral canthal involvement were not predictive of ocular complications.

CONCLUSION

Predictive factors for ocular complications in patients with periocular infantile hemangiomas are diameter greater than 1 cm, a deep component, and upper eyelid involvement, with size being the most consistent predictor. These patients should be promptly referred to an ophthalmologist, and treatment should be strongly considered.

Is Propranolol Safe and Effective for Outpatient Use for Infantile Hemangioma? A Prospective Study of 679 Cases From One Center in China

BACKGROUND

The protocol for the treatment of infantile hemangioma with propranolol varies among different clinical centers.

METHODS

Six hundred seventy-nine patients who were 1 to 12 months old were recruited in this prospective study to receive propranolol treatment. The response to the propranolol therapy was classified as 4 levels. The results were primarily evaluated using color Doppler ultrasound examinations before and after propranolol treatment.

RESULTS

The response was excellent in 176 (25.9%), good in 492 (72.5%), stable in 5 (0.7%), and poor in 6 (0.9%) of the patients. The mean age at the initiation of the therapy was 3.3 months (range, 1 to 10.9 months) and the mean duration of the therapy was 7.1 months (range, 3-17 months). The mean duration of the follow-up time after the discontinuation of the therapy was 5.3 months (range, 3-17 months). Regrowth of the hemangioma was observed in 92 cases (13.5%). Seventy-nine (11.6%) of the parents complained of their child's minor discomfort during the therapy.

CONCLUSIONS

Propranolol (2 mg/kg per day) may significantly reduce the size of a hemangioma. As an outpatient therapy, propranolol was found to be safe for Chinese children and to have minor side effects.

Beta Blockers in the Treatment of Periocular Infantile Hemangiomas: A Review

Infantile hemangiomas (IH) are the most common benign tumor of infancy, and in the periocular region can be associated with permanent visual impairment from amblyopia. Previous treatment options included systemic and local corticosteroids, surgical excision, laser therapy, and in rare cases immunomodulatory therapy, many of which had variable outcomes with undesirable side effect profiles. Since their initial use for IH in 2008, beta blockers have become the mainstay of therapy for periocular IH due to their excellent clinical efficacy and tolerability. While the exact mechanism of action of beta blockers in IH has not been fully elucidated, both oral and topical therapy have demonstrated low rates of adverse events and improved outcomes in the management of periocular IH. This review summarizes the most recent studies on the clinical outcomes, management, and guidelines for the treatment of periocular IH with topical and oral beta blockers.

Nanomedicine in the application of uveal melanoma

Rapid advances in nanomedicine have significantly changed many aspects of nanoparticle application to the eye including areas of diagnosis, imaging and more importantly drug delivery. The nanoparticle-based drug delivery systems has provided a solution to various drug solubility-related problems in ophthalmology treatment. Nanostructured compounds could be used to achieve local ocular delivery with minimal unwanted systematic side effects produced by taking advantage of the phagocyte system. In addition, the in vivo control release by nanomaterials encapsulated drugs provides prolong exposure of the compound in the body. Furthermore, certain nanoparticles can overcome important body barriers including the blood-retinal barrier as well as the corneal-retinal barrier of the eye for effective delivery of the drug. In summary, the nanotechnology based drug delivery system may serve as an important tool for uveal melanoma treatment.

Hemangiomas and the eye

Infantile hemangiomas are a common vascular birthmark with heterogeneous presentations and unique growth characteristics with early rapid growth and eventual self-involution. Hemangiomas that develop around the eye have the potential for inducing amblyopia by several mechanisms and may eventually result in permanent visual impairment in otherwise healthy infants. Segmental periocular hemangiomas carry the additional risk of associated structural anomalies and PHACE syndrome. In recent years, the treatment of periocular hemangiomas has been revolutionized by the serendipitous discovery of the effectiveness of beta-blockers (systemic and topical), with most experts viewing these as first-line therapies. The management of periocular hemangiomas should involve a close partnership between an ophthalmologist and dermatologist or other relevant specialists familiar with the unique clinical features, differential diagnosis, treatment approaches, and potential complications.

Diagnosis and Management of Infantile Hemangioma

Infantile hemangiomas (IHs) are the most common tumors of childhood. Unlike other tumors, they have the unique ability to involute after proliferation, often leading primary care providers to assume they will resolve without intervention or consequence. Unfortunately, a subset of IHs rapidly develop complications, resulting in pain, functional impairment, or permanent disfigurement. As a result, the primary clinician has the task of determining which lesions require early consultation with a specialist. Although several recent reviews have been published, this clinical report is the first based on input from individuals representing the many specialties involved in the treatment of IH. Its purpose is to update the pediatric community regarding recent discoveries in IH pathogenesis, treatment, and clinical associations and to provide a basis for clinical decision-making in the management of IH.

Infantile hemangioma: treatment with surgery or steroids

BACKGROUND AND PURPOSE

Infantile hemangiomas (IH) often pose a significant risk to visual development. The lesions interfere with visual development by causing deprivation, astigmatism, or strabismus. Propranolol has been suggested as the new standard of care for treatment of IH. Alternative treatments such as intralesional steroids or surgery may need to be considered as equal or better treatments in some cases. The purpose of this study was to evaluate the potential risks and benefits of the various modalities for periocular IH.

METHOD

A literature search was conducted for IH and propranolol, steroids, and surgery. The pertinent published literature on surgical resection of IH were reviewed and summarized. A retrospective analysis was also performed of the Vanderbilt Children's Hospital (VCH) surgical case series of twelve children who underwent surgical resection of a sight threatening IH.

RESULTS

Seven articles reported twenty or more patients treated with propranolol for IH. Many of these patients only had a partial response to propranolol in spite of months of treatment. In addition to the impact on IH, propranolol has been demonstrated to block neural pathways critical for learning and memory. Twelve children underwent surgical resection of a visual threatening IH at VCH. Two of these children had failed treatment with oral propranolol. The average time of surgery was 80 minutes. All twelve children had immediate resolution of the visual compromise.

CONCLUSION

Early surgical intervention can successfully and quickly result in excellent visual and anatomic outcomes. Propranolol may have unrecognized neurocognitive impact and should be reserved for those lesions unamenable to surgical or local steroid injection.

Approach to the patient with an infantile hemangioma

Infantile hemangioma is the most common soft tissue tumor of childhood. Despite its frequency, it has only been in the last decade that these lesions have been better characterized and become the subject of significant clinical and translational research. Although most infantile hemangiomas are uncomplicated and do not require intervention, they can be a significant source of parental distress, cosmetic disfigurement, and morbidity. The wide spectrum of disease in the morphology of these lesions and in their behavior has made it difficult to predict the need for treatment and has made it challenging to establish a standardized approach to management.

Periocular capillary hemangioma: management practices in recent years

Purpose

To present a case series on the management options for capillary hemangiomas involving the eyelid and orbit.

Methods

This is a retrospective chart review of clinically diagnosed capillary hemangioma cases involving the periocular region treated at two local eye institutions. The patients’ demographics and clinical presentation – including visual acuity, refractive error, periorbital and orbital examinations, and ultrasound and magnetic resonance imaging findings – were reviewed. The clinical progression, modalities of treatment, and treatment outcomes were studied.

Results

Sixteen cases of capillary hemangiomas involving the eyelid and orbit were studied. The mean age at consultation was 9.6 months (range: 1 month–72 months). The majority were females (75%), with 50% presenting as upper-eyelid hemangiomas and the remaining as lower-eyelid (38%) and glabellar (12%) lesions. Combined superficial and deep involvement was common (64%). Cases whose lesions were located at the upper eyelid or superior orbit led to amblyopia (25%). Fifty-six percent of cases (9/16) were managed conservatively, and 44% (7/16) underwent treatment with either single-agent (n = 4) or combined treatments (n = 3).

Conclusion

Close monitoring of visual development and prompt institution of amblyopia therapy for children with periocular capillary hemangiomas generally preserve vision. Extensive lesions that affect the visual axis require local and systemic treatments, alone or in combination, in order to reduce the size and impact of lesions on the eyeball, to reduce induced refractive error and visual occlusion, and to prevent the development of amblyopia, in order to achieve good visual outcomes.

Parenteral corticosteroids followed by early surgical resection of large amblyogenic eyelid hemangiomas in infants

Background

The purpose of this study was to evaluate the results and complications of early surgical resection of large amblyogenic subdermal eyelid hemangiomas in infants after prior short-term parenteral administration of corticosteroids.

Methods

Sixteen infants were given dexamethasone 2 mg/kg/day in two divided doses for three consecutive days prior to scheduled surgical excision of large eyelid hemangiomas. The lesions were accessed via an upper eyelid crease, subeyebrow incision, or a lower eyelid subciliary incision.

Results

In all cases, surgical excision of the entire lesion was possible with no significant intraoperative or postoperative complications. The levator muscle/aponeurosis complex was involved in 31.25% of cases and was managed by reinsertion or repositioning without resection. A satisfactory lid position and contour with immediate clearing of the visual axis was achieved in all but one case (93.8%).

Conclusion

Parenteral corticosteroids helped in reducing volume and blood flow from the hemangiomas, allowing for very early total excision of large subdermal infantile hemangiomas without significant intraoperative hemorrhage. This resulted in immediate elimination of any reason for occlusion amblyopia. Long-term follow-up of visual development in these patients would help to demonstrate the effectiveness of this strategy compared with more conservative measures.

Scleral hemangioma: case report and response to propranolol

Scleral infantile hemangiomas are rare. We describe a patient who presented at 3 months of age with an enlarging infantile hemangioma on the sclera of the left eye. He had two other hemangiomas on the left eyebrow and chest. Treatment with propranolol resulted in marked improvement of all of his hemangiomas. He did not develop any ocular complications.

Treatment of infantile capillary hemangioma of the eyelid with systemic propranolol

PURPOSE

To assess the efficacy and safety of systemic propranolol for infantile capillary hemangiomas of the eyelid.

DESIGN

Prospective, interventional cases series.

METHODS

All patients with eyelid infantile capillary hemangiomas at risk of developing amblyopia seen between January 2009 and January 2012 at the University Federico II, Naples, Italy, were treated with systemic propranolol (2 mg/kg body weight per day). Maximum length of treatment was 4 months, and propranolol was suspended when complete regression of lesions was obtained or in case of collateral effects. Minimum follow-up was 6 months.

RESULTS

Of 17 patients with eyelid infantile capillary hemangiomas, 3 were excluded for asthma and 14 (7 males, 7 females; mean age, 20.85 ± 29.7 months; range, 1 to 72 months) underwent treatment with systemic propranolol. Capillary hemangiomas involved the upper eyelid in 10 cases and the lower eyelid in 4 cases. Propranolol was stopped in 1 case for hypotension and in 1 case for allergy. Treatment was administered over a mean of 2.5 ± 1.3 months (range, 1 to 4 months); the mean follow-up was 10.64 ± 8.7 months (range, 6 to 39 months). Ten patients were younger than 1 year and demonstrated complete regression. Two patients older than 5 years also benefited from treatment. In 4 cases, amblyogenic astigmatism was present and decreased from 1.25 ± 0.5 diopters before treatment to 0.25 ± 0.2 diopters after treatment. No regrowth was observed.

CONCLUSIONS

Four months of treatment with oral propranolol for eyelid infantile capillary hemangiomas led to complete regression of the lesion in patients younger than 1 year. No major collateral effects were observed. Treatment also may be considered in patients older than 5 years to reduce astigmatism and for aesthetic purposes.

Isolated infantile myofibromatosis of the upper eyelid: uncommon localization and long-term results after surgical management

Myofibroma, the most common juvenile fibrous disorder in infancy, usually manifests as a solitary soft tissue tumor and less commonly as simultaneous multiple tumors in both soft tissue and bones. Infantile myofibromatosis is well described in the head and neck, but cutaneous lesions rarely occur in the periorbit and orbit, where fast growth and bone damage can mimic malignant tumors. We describe a case of a solitary periorbital myofibroma in a newborn. Treatment consisted of partial excision of the tumor. Histologic and immunohistochemistry analyses provided the diagnosis of infantile myofibromatosis. The patient remains disease-free at 10 years of age, but with some visual impairment. Infantile myofibromatosis is an uncommon tumor with exceptional periorbital involvement. Differential diagnosis can be difficult when it is solely based on histologic assessment. Immunohistochemistry evaluation demonstrating cytoplasmic actin filaments in neoplastic spindle cells confirms the diagnosis. As soon as the diagnosis is made, chest and abdominal imaging must be performed to evaluate the overall prognosis and direct treatment. The treatment of choice is early conservative surgery to minimize functional and/or esthetic damage. Complete tumor excision is not always possible. Lengthy ophthalmologic monitoring is required to detect the onset of amblyopia.

Current concepts in the management of periocular infantile (capillary) hemangioma

PURPOSE OF REVIEW

To review and evaluate the medical literature on new treatments for periocular infantile (capillary) hemangioma. Recent studies have shown a promising new therapy for infantile hemangioma using nonselective β-blockers, including oral propranolol and topical timolol.

RECENT FINDINGS

Conventional treatments for infantile hemangioma include the use of corticosteroids, laser, surgery, and immunomodulator therapy. Recently, systemic and topical β-blockers have been used to successfully treat infantile hemangioma. The drugs' mechanism of action remains uncertain, but plausible theories include vasoconstriction, modulation of pro-survival signal transduction pathways, and endothelial cell apoptosis. Whereas no life-threatening adverse events from β-blocker treatment have been described, there have been reports of bradycardia, hypotension, bronchospasm, hypoglycemia, and electrolyte disturbances resulting from systemic use of propranolol to treat infantile hemangioma. Sleep and gastrointestinal disturbances have also been frequently reported. Topical timolol application for localized, superficial tumors may confer similar efficacy as oral propranolol while reducing systemic effects.

SUMMARY

Despite the recent explosion of interest surrounding this novel treatment, current treatment and protocol-monitoring recommendations are based largely on the experience of individual centers. Several randomized controlled studies are currently underway, the results of which will guide future standard-of-care treatment for infantile hemangioma.

Distribution of propranolol in periocular tissues: a comparison of topical and systemic administration

PURPOSE

Oral propranolol has become a promising treatment of capillary hemangiomas (CHs) despite concerns of side effects associated with systemic beta-blockers. The objective of this study was to investigate the distribution of propranolol in periocular tissues and in plasma after topical application of propranolol as compared with intravenous and oral administration of propranolol.

METHODS

Each rabbit received propranolol as ophthalmic solution (1%) in one eye (1.5 mg dose), intravenous injection (1.5 mg dose), or commercially available propranolol oral solution (5 mg dose). The periocular tissues (e.g., eyelids and extraocular muscles) and blood were collected and assayed for propranolol.

RESULTS

After topical instillation of 1.5 mg propranolol, high amounts of propranolol were rapidly delivered to the eyelids and extraocular muscles (4-32 μg/g at 1 h after dosing). The drug in these tissues was slowly cleared, and significant amounts of the drug (>0.4 μg/g) were still present at 24 h after the topical application. After oral administration of a clinically relevant dose of 5 mg propranolol, the drug concentrations in the periocular tissues were relatively low (<0.4 μg/g) at 1 h after dosing and generally undetectable at 8 h after dosing. After an intravenous injection of 1.5 mg propranolol, the drug concentrations in the eyelids and extraocular muscles were in the range of 0.2-1 μg/g at 1 h after dosing. The plasma concentration of the drug after the intravenous injection was significantly higher than that after topical application of the same dose. The higher drug concentrations in the periocular tissues of the treated eyes as compared with untreated eyes suggest direct penetration of the drug into the periocular tissues from the administration site after topical application.

CONCLUSIONS

Topical administration can provide increased concentrations of propranolol in the periocular tissues and, thus, is superior to systemic administration for the treatment of periocular CH.

Propranolol in the management of periorbital infantile haemangioma

BACKGROUND

Infantile haemangiomas are the commonest tumours of the orbit in children. Treatment is usually expectant, unless they are visually threatening. Although steroids, other pharmacological and surgical treatment modalities have their place, there are risks involved. A previous case series reported the successful use of propranolol for infantile haemangioma. The safety and efficacy of propranolol in the treatment of periorbital haemangioma was reviewed in a serious of our patients.

METHODS

We performed a retrospective review of patients seen by two ophthalmologists (TJS and GAG), collecting data on colour, size of lesion, duration of treatment and side-effects of treatment. Our main outcome measures were colour and size of infantile haemangioma before and after treatment, the change in astigmatism of our patients and the incidence of complications from propranolol.

RESULTS

We reviewed 10 patients with infantile haemangioma. They were treated with propranolol oral syrup 2 mg/kg/day in divided doses for a mean duration of 32.8 (range 12-42) weeks. All our patients had a reduction in colour and size of the lesions. The mean lesion size decreased from 756.7 to 543.2 mm(2) after treatment (P = 0.075). Five patients had significant astigmatism and 60% had successful reduction of astigmatism after treatment. None of our patients suffered significant side-effects of propranolol.

CONCLUSION

Propranolol appears to be a safe and effective treatment in the management of infantile haemangioma.