Risk factors for amblyopia in children with capillary hemangiomas of the eyelids and orbit

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.

Long-Term Results of Oral Propranolol Treatment Protocol for Periocular Infantile Hemangioma: Should There Be Any Contraindication?

PURPOSE

The authors report long-term results of the oral propranolol treatment protocol for periocular infantile hemangioma regardless of conventional indications.

METHODS

This is a retrospective study (2008-2018) on children with propranolol treatment protocol for periocular infantile hemangioma and last follow-up (FU) of ≥4 months after treatment and age of >24 months. After systemic evaluation, it was started with 0.5 and increased by 0.5 every 3 days to reach 2 mg/kg/day. If there was no good response, it would be gradually increased up to 3 mg/kg/day. Tapering (0.5 mg/kg/day every 4 weeks) was started when patients were on treatment for ≥6 months and ≥12 months old and there was no change in the infantile hemangioma size for ≥3 months. Rebound growth was based on the parents' report and would be treated by increasing the dose to at least 2 mg/kg/day for 3 months. FU was either in-person or via social media. Change in periocular infantile hemangioma size on the photos was scored by 3 masked observers (visual analog scale) and presented as excellent (≥50% reduction), good (1%-49%), fair (no change), and failure (enlarged).

RESULTS

Forty-three patients were included. Orbital involvement was in 49%, ptosis in 58%, and risk of amblyopia in 63%. Mean treatment, tapering, and FU duration were 37, 13, and 74 months, respectively. Mean age at presentation, start of propranolol treatment protocol, tapering, stop, and last FU were 1.5, 5, 29, 42, and 78 months, respectively. Twenty-seven patients received 2, seven 2.5, and nine 3 mg/kg/day. Mean visual analog scale significantly increased from 43% (FU1) to 92% (last FU) when 97.6% of patients showed an excellent response. The remaining skin lesions were observed in 35%. No side effect was reported.

CONCLUSIONS

Long-term results of the propranolol treatment protocol for periocular infantile hemangioma showed an excellent response in 97.6% of patients with no side effects. A residual skin lesion was observed in 1/3 of the patient.

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.

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.

Effect of Oral Propranolol on Periocular Infantile Capillary Hemangioma: Outcomes Based on Extent of Involvement

PURPOSE

To evaluate the efficacy of oral propranolol in the treatment of periocular infantile capillary hemangioma (CHI) based on the involvement of embryological facial placodes and their extent of anatomical involvement.

METHODS

Retrospective study of 27 patients.

RESULTS

The mean age at the presentation of periocular CHI was 4 months (median, 3 months; range, <1-14 months). There were 11 (41%) males and 16 (59%) females. Based on embryological facial placodes, the involvement was focal in 16 (59%) cases and segmental in 11 (41%) cases. Based on the anatomical distribution, the lesions were preseptal in 4 (15%), postseptal in 13 (48%), and combined in 10 (37%) cases. The duration of use of oral propranolol was 10 months (median, 10 months; range, 4-16 months). Overall, the mean % resolution of periocular CHI was 78% (median, 90%; range, 20%-100%). The mean percentage resolution of focal lesions was 69% (median, 83%; range, 20%-100%), and segmental lesions were 92% (median, 95%; range, 70%-100%). The mean percentage resolution of preseptal component of lesions was 94% (median, 95%; range, 80%-100%) and postseptal component was 74% (median, 85%; range, 20%-100%) over a mean follow-up period of 16 months (median, 15 months; range, 4-37 months). Four (15%) patients exhibited flare-up of lesion after tapering oral propranolol.

CONCLUSION

Oral propranolol is effective in the treatment of periocular CHI. Segmental and preseptal lesions respond better to the treatment compared to focal and postseptal lesions.

Capillary Hemangioma Presenting as a Scleral Vascular Lesion in a Child

A 7-year-old healthy girl presented for an evaluation of a left vascular scleral mass. The lesion appeared spontaneously with no history of trauma, coagulopathy, or topical medication use. It was nontender, enlarging, and did not extend intraocularly. Her OS vision was 20/20, and the remainder of her eye examination was normal. Evaluation of the ocular mass included B-scan ultrasound, ultrasound biomicroscopy, anterior segment optical coherence tomography (OCT), and orbital MRI. The anterior segment OCT demonstrated vessels within the mass with no defined capsule. The orbital MRI confirmed a lesion isolated to the scleral layers of the globe, with low blood flow. The patient had a partial response to oral propranolol. Because the lesion vessels began to extend into her corneal endothelium, there was a concern for malignancy. A biopsy confirmed a benign intrascleral capillary hemangioma. Discontinuation of the propranolol demonstrated stability of the lesion 6 months later.

[Orbital hemangiomas: capabilities of modern neuroradiological diagnostics]

MATERIAL AND METHODS

In the period from 2010 to 2016. 14 patients with cavernous hemangioma (CH) and 2 patients with capillary hemangioma (CapH) of the orbit were examined. The age of CH patients varied from 17 to 67 years (median, 53 years); 8 females and 6 males. The age of CapH patients was 35 and 54 years. All patients underwent surgery with subsequent histological verification. CT-perfusion was performed in 10 CH patients and 2 CapH patients according to a developed low-dose protocol (80 kV, 200 mAs, t_scan=40 s) with allowance for a target localizer (80 kV, 120 mAs) and at a maximum radiation dose of not more than 4.0 mZv. Neoplasm microcirculation was quantitatively assessed by calculating hemodynamic parameters: blood flow velocity (BFV), blood volume (BV), and mean transit time (MTT). MRI without and with contrast enhancement was performed in 11 CH patients and 2 CapH patients according to the ophthalmologic protocol (Signa GE, 3.0 T) accepted at the Institute: without contrast enhancement - T1, T2, and T2-FLAIR modes, T1 and T2 with a Fat Sat technique at a scan thickness of 3 mm, and DWI MRI; contrast enhancement - T1 (three projections) mode, including the Fat Sat technique. SWAN (n=2) and non-contrast MR perfusion ASL (n=3) were also used. Diffusion-weighted images (DWI) were processed with calculation of the apparent diffusion coefficient (ACD).

RESULTS

In all CH patients, CT-perfusion revealed low perfusion parameters of blood flow: BV_CH=0.86±0.37 mL/100 g, BFV_CH= 4.89±2.01 mL/100 g/min with a high mean transit time MTT_CH=10.13±3.05 s compared to the same parameters of blood flow in the normal white matter: CBV_NormWM=1.63±2.22 mL/100 g, CBFV_NormWM=9.72±3.13 mL/100 g/min, and MTT_NormWM=6.76±2.78 s. In CapH cases, significantly increased blood flow velocity and volume values and a low MTT value in the tumor were observed: BV_CapH=10.30±4.10 mL/100 g, BFV_CapH=119.72±53.13 mL/100 g/min, and MTT_CapH=4.35±1.79 s. In the case of orbital hemangiomas, optimal MRI modes were T1 and T2 with the Fat Sat technique, a scan thickness of 3 mm, and intravenous contrast enhancement. The revealed pattern of contrast agent accumulation by CH, initially in the central part and then in the periphery, may be a useful radiographic sign in the differential diagnosis with other orbital tumors.

CONCLUSION

Modern CT- and MRI-based diagnostics of orbital hemangiomas provides not only the exact location, size, and spread of the lesion but also reveals the characteristic structural features of these tumors, and the use of perfusion techniques visualizes hemodynamics of the tumors. CT-perfusion-based hemodynamic parameters of cavernous hemangiomas typical of this type of hemangiomas may be used in the differential diagnosis with other tumors of this location. The use of contrast enhancement and the Fat Sat technique with a scan thickness of not more than 3 mm is optimal for MRI diagnostics of orbital hemangiomas.

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.

Vascular Anomalies of the Head and Neck Region

Vascular anomalies of the head and neck region are a complex group of lesions that challenge the head and neck physicians. From the very understanding of the difference between its two distinct forms, hemangiomas and vascular malformations to its management remain confusing. The review of this anomaly attempts at comprehensively understanding the disease. Vascular anomalies are easily diagnosed by their clinical presentation, but choice of imaging and management for this spectrum of lesions is varied. The author attempts to categorize the required imaging for the lesion with suggestions on the management of both hemangiomas and vascular malformations. The available treatment options are discussed, and a comprehensive algorithm for management is suggested. Further research in developing drugs that could restrict the growth of these lesions would be the future of the management of vascular lesions.

Clinical and Radiological Evaluation of Periocular Infantile Hemangioma Treated With Oral Propranolol: A Case Series

PURPOSE

To evaluate the efficacy of propranolol (3 mg/kg/day) in the treatment of periocular infantile hemangioma (IH) based on clinical and radiological findings.

DESIGN

Prospective interventional case series.

METHODS

Study of previously untreated infants with IH conducted at the ophthalmology outpatient service of HC-FMUSP (Brazil). The patients were submitted to a complete ophthalmologic examination, gray-scale and Doppler ultrasonography, and nuclear magnetic resonance imaging. Lesion regression was evaluated clinically and radiologically during follow-up. The sample consisted of potentially amblyogenic and disfiguring lesions. The dose was increased at weekly intervals, from 0.5 mg to 3 mg/kg/day. The age at onset of treatment was 2-28 months. Follow-up lasted up to 48 months.

RESULTS

Nine infants with periocular IH were treated with propranolol (oral) for 2-12 months (mean: 7.1 months). Clinical regression (attenuation of color and reduction in size) was observed in 88% during the first days of treatment. Partial recurrence was observed during follow-up in a patient treated for 6 months. On Doppler ultrasonography, during the first 6 months of treatment lesion volume and vascular density decreased while the arterial resistivity index (RI) increased, followed by a decline.

CONCLUSION

Propranolol at 3 mg/kg/day was clinically and radiologically efficacious against deep IH in the proliferative stage, with no recurrence in patients treated for 12 months. RI might help determine when treatment can be safely interrupted.

Combined oral propranolol with intralesional injection of triamcinolone acetonide in treatment of infantile periocular hemangiomas

Aim

To evaluate the clinical effectiveness of combined oral propranolol with intralesional injection of triamcinolone acetonide in the treatment of infantile periorbital capillary hemangioma.

Patients and Methods

This prospective interventional study included children diagnosed with periocular infantile hemangiomas in the proliferative phase with vision-threatening lesions. The children presented to the oculoplastic unit in Sohag University Hospital in the period between January 2016 and February 2017 and were treated with a combined intralesional injection of triamcinolone acetonide with oral propranolol, with a follow-up period of 6 months. Treatment response was evaluated according to the size of the tumor (horizontal diameter); additionally, complications of both treatment methods were recorded.

Results

This study included 33 infants: 21 females (64%) and 12 males (36%). The mean age at the time of injection was 4.9±2.6 months. The study included three modes of treatment response: regression of the tumor, 28 patients (85%); stabilization, three patients (9%); and failure, two patients (6%), which necessitated repeated intralesional injection of triamcinolone but with minimal response. Regarding complications, only one patient reported with subconjunctival hemorrhage during intralesional injection of steroids; there were no recorded cases of hypotension, bradycardia, or hypoglycemia during the course of oral propranolol treatment. After the end of the follow-up period, there were no reported cases of recurrent increase in the size of the regressed group of infantile hemangiomas with stable tumor size.

Conclusion

Combined oral propranolol with intralesional injection of triamcinolone acetonide is the effective method of treatment for infantile periorbital capillary hemangioma with minimal adverse effects.

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.

Orbital Hemangioma with Intracranial Vascular Anomalies and Hemangiomas: A New Presentation of PHACE Syndrome?

We present two cases of infants with a similar constellation of clinical findings: retro-orbital infantile hemangioma (IH), internal carotid artery (ICA) arteriopathy, and intracranial IH. In both cases, intracranial vascular anomalies and hemangiomas were found incidentally during evaluation of unilateral proptosis. Neither infant had evidence of cutaneous segmental IH of the face or neck, which might have provided a clue to the diagnosis of PHACE syndrome or of intracranial hemangiomas. In one case, intracranial involvement was particularly extensive and function threatening, with mass effect on the brain parenchyma. These cases serve to highlight the fact that clinical findings of proptosis, globe deviation, and strabismus should prompt immediate imaging to confirm the presence of orbital IHs and to exclude other diagnoses. Moreover, based on our cases and the embryologic origin of the orbit as a unique developmental unit, patients with confirmed retro-orbital IHs should undergo evaluation for anomalies associated with PHACE syndrome. Patients with orbital IHs and an additional major criterion for PHACE syndrome should be considered to have definite, and not just possible, PHACE syndrome.

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.

[Current aspects of eyelid, lacrimal and orbital surgery in childhood]

BACKGROUND

During childhood the spectrum of disorders of the eyelid, the lacrimal drainage system and the orbit as well as the subsequent therapeutic management differ from those in adults.

OBJECTIVES

This review outlines the clinical picture and treatment of the most common eyelid, lacrimal drainage and orbital diseases in childhood.

METHODS

The study comprises a PubMed literature review and own clinical results.

RESULTS

The most common eyelid disorders in childhood include congenital malpositions, such as ptosis or entropium, which may require fast surgical correction in order to prevent amblyopia. For connatal dacryostenosis a step-by-step therapeutic approach is recommended: (1) conservative treatment using lacrimal sac massage, astringent eye and nose drops, (2) irrigation and probing of the nasolacrimal system and (3) irrigation, probing and silastic tube intubation under general anesthesia. Benign orbital lesions such as dermoid cysts can be removed at pre-school age. Using systemic beta blockers is a novel conservative approach in the treatment of capillary hemangioma, which should precede surgical interventions.

CONCLUSION

Eyelid and orbital diseases during childhood may require fast surgical intervention to prevent amblyopia. Initial conservative treatment is recommended for connatal dacryostenosis and capillary hemangioma.

Eye disorders in newborn infants (excluding retinopathy of prematurity)

A screening eye examination is an essential part of the newborn assessment. The detection of many ocular disorders in newborn infants can be achieved through careful observation of the infant's visual behaviour and the use of a direct ophthalmoscope to assess the ocular structures and check the red reflex. Early diagnosis and subspecialty referral can have a critical impact on the prognosis for many ocular conditions, including potentially blinding but treatable conditions such as congenital cataracts, life-threatening malignancies such as retinoblastoma and harbingers of disease elsewhere such as sporadic aniridia and its association with the development of Wilms tumour.

Propranolol as first-line treatment in orbital infantile haemangiomas: a case series

PURPOSE

To highlight the importance of Magnetic Resonance Imaging (MRI) and the use of propranolol as both a final diagnostic tool and adequate treatment for orbital Infantile Haemangiomas (IHs).

METHODS

A retrospective study was conducted using a case series of 5 infants diagnosed with orbital IH. All patients presented with progressive unilateral proptosis and were at high risk of developing amblyopia, some had combined swelling of the eyelid, impaired eye movements or exposure keratopathy. Propranolol was administered in an initial dose of 0.6 mg/kg/day orally divided in three daily doses and increased in 4 days to 2.7 mg/kg/day. MRI was performed in all children.

RESULTS

Striking MR characteristics of an IH lesion were seen in each of our 5 cases, including the presence of flow voids, high contrast enhancement, hypo-intense T1W signal, iso- to hyper intense T2W signal, and lobulated appearance. All patients showed a quick clinical response to treatment, resulting in significant reduction in tumour size within a range of 1-3 weeks and almost complete regression of the lesion at the end of the treatment schedule.

CONCLUSIONS

Our study adds another 5 cases to the growing body of reports confirming the efficacy and safety - under controlled circumstances - of propranolol therapy in orbital IH management, in which we highlight the use of propranolol as both a final diagnostic tool and as an adequate treatment.

Treatment of periorbital infantile haemangiomas: a systematic literature review on propranolol or steroids

AIM

The aim of this study was to compare the efficacy and safety of propranolol versus corticosteroids for the treatment of periorbital infantile haemangiomas (IHs).

METHODS

A literature review using PubMed, Ovid Medline, EBSCO, Springer, Web of Knowledge, Cochrane Library, CNKI and associated references before 2 March 2013 was conducted. The main outcomes were distribution of locations, response rate, rebound growth rate, spherical and cylinder power before and after treatment, amblyopia rate and adverse events.

RESULTS

Thirty-one studies including 425 patients met the inclusion criteria. A total of 70.6% of patients were female, 89.6% of the periorbital IHs were located in the upper or lower eyelid area. The most common administration routes involved oral propranolol and intralesional injection of corticosteroids. The mean response rate was 94.0% for propranolol and 82.3% for corticosteroid (P = 0.001). The rebound growth rate was 13.9% for propranolol and 12.0% for steroids (P = 0.71). Astigmatism was reduced in both propranolol and steroid studies (P < 0.0001, P < 0.0001), but a significant reduction in spherical power was only demonstrated in propranolol studies (P = 0.005). A total of 31.1% of patients treated with corticosteroids developed post-operative amblyopia compared with 16.7% of patients treated with propranolol (P = 0.04). Oral propranolol seemed to induce more temporary adverse events than intralesional corticosteroids administration (24.0% vs. 9.6%, P = 0.006).

CONCLUSION

Propranolol may represent an effective therapy for periorbital IHs compared with the use of corticosteroids; however, further randomised control studies are needed to compare adverse events.

Topical Treatment for Orbital Capillary Hemangioma in an Adult Using a β-Blocker Solution

Purpose

To report a case of orbital capillary hemangioma in an adult who was successfully treated with topical timolol maleate 0.5% solution.

Methods

Case report.

Results

A 43-year-old female presented both superficial and deep orbital capillary hemangioma. Topical timolol maleate was applied twice daily. The superficial lesions have nearly disappeared after 1 year of treatment. The deeper lesions have also been reduced in size according to MRI.

Conclusion

We report an adult patient with a relatively large orbital capillary hemangioma who was successfully treated with a topical β-blocker solution. This treatment might be applicable for orbital capillary hemangiomas, regardless of the patient's age, because of its effectiveness and safety.

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.

Primary surgical excision for pediatric orbital capillary hemangioma

We report the technique and outcome of surgical excision of subcutaneous orbital capillary hemangioma causing eye globe displacement in two children. Primary surgical excision was performed with blunt dissection along the tumor walls using a cotton-tipped applicator as the dissecting tool with simultaneous outward gentle traction on the tumor wall. Despite the deep and extensive orbital involvement, complete excision of the hemangiomas was achievable with this technique, which permitted excellent visualization of the surgical planes throughout the procedures. Deep and extensive pediatric orbital capillary hemangioma can be surgically excised with the suggested technique, which obviates the need for intralesional or systemic medical therapy, yielding optimal cosmetic and functional outcomes, shortly after surgery.

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.

Corneal epithelial permeability: ethnic differences between Asians and non-Asians

PURPOSE

To ascertain whether a difference in the permeability of the corneal epithelium to fluorescein (Pdc) exists between Asians and non-Asians.

METHODS

From a multi-study database we extracted 632 records of baseline, open-eye Pdc measurements taken on both eyes of 176 subjects. Subjects were awake for a minimum of 4h before measurement, and were free of ocular disease and central corneal staining. Pdc was transformed by natural logarithm to better approximate normality for statistical tests.

RESULTS

The mean ln(Pdc) in the Asian group was significantly greater than in the non-Asian group [-2.34 ln(nm/s) vs. -2.58 ln(nm/s); p<0.001].

CONCLUSIONS

Compared with non-Asians, Asians exhibited a less negative ln(Pdc), which translates to a higher Pdc and a more permeable corneal epithelium. We speculate that this may be related to anatomic differences responsible for greater eyelid tension in Asians.

Propranolol accelerates adipogenesis in hemangioma stem cells and causes apoptosis of hemangioma endothelial cells

BACKGROUND

Infantile hemangiomas can cause significant morbidity during proliferation, yet there is no U.S. Food and Drug Administration-approved treatment. They are believed to form from hemangioma stem cells, which differentiate toward a hemangioma endothelial cell phenotype. Recently, propranolol has demonstrated effectiveness in treating complicated infantile hemangiomas. The authors hypothesize that propranolol facilitates their involution by altering cellular behavior in both hemangioma endothelial and stem cells.

METHODS

Hemangioma endothelial and stem cells were isolated from resected infantile hemangioma specimens. Cells were treated with 100 μM propranolol for 48 hours, and apoptosis was determined by the presence of annexin V antibody. Proliferation of stem and endothelial cells was assessed after treatment with 50 or 100 μM propranolol or vehicle, for 72 and 96 hours, respectively. Adipogenesis was induced in stem cells with and without propranolol. Pro-adipogenic genes PPARδ, PPARγ, C/EBPα, C/EBPβ, C/EBPδ, RXRα, and RXRγ were analyzed by quantitative polymerase chain reaction.

RESULTS

Annexin V levels were increased in propranolol-treated endothelial cells but not in stem cells. Proliferation of stem and endothelial cells was inhibited by propranolol in a dose-dependent manner. Propranolol-treated stem cells demonstrated accelerated adipogenesis when compared with untreated controls. Transcript levels of C/EBPβ (p < 0.05), RXRγ (p < 0.05), and PPARγ (p < 0.02) were significantly increased when treated with 50 or 100 μM propranolol; and C/EBPδ (p < 0.05), RXRα (p < 0.05), and PPARδ (p < 0.01) transcripts were increased when treated with 100 μM propranolol. C/EBPα transcript levels remained unchanged at either dose.

CONCLUSIONS

Propranolol increased apoptosis of hemangioma endothelial cells, but not stem cells, and accelerated adipogenesis of hemangioma stem cells. Thus, propranolol likely accelerates involution to fibrofatty residuum.

Incidence and clinical characteristics of periocular infantile hemangiomas

OBJECTIVE

To report the incidence, demographics, and clinical findings among a population-based cohort of children with periocular infantile hemangiomas.

METHODS

The medical records of all patients (<19 years of age) diagnosed as having periocular infantile hemangiomas while residing in Olmsted County, Minnesota, from January 1, 1965, through December 31, 2004, were retrospectively reviewed.

RESULTS

Forty-three children were diagnosed as having periocular infantile hemangiomas during the 40-year period, yielding an incidence of 5.4 per 100,000 individuals younger than 19 years (95% CI, 3.8-7.1) or a birth prevalence of 1 in 1586 live births. Thirty children (70%) were female (P<.001). There was a history of maternal infertility in approximately 1 in 5 children and premature birth in 1 in 8 children. Twenty-six children (61%) had other abnormalities, including secondary hemangiomas in 9 (21%). Forty-one patients (95%) had unilateral disease, and 37 hemangiomas (86%) were located on the upper eyelid.

CONCLUSIONS

In this population-based study, periocular infantile hemangiomas occurred in 1 in 1586 live births and were most prevalent on the unilateral upper eyelid of white female patients. Prevalent associations included maternal infertility and premature birth. Other abnormalities, including secondary hemangiomas in 1 in 5 children, were common in this cohort.

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.

Infantile hemangiomas: A review

Infantile hemangiomas (IH) are the most common eyelid and orbital tumors of childhood. Although they are considered benign lesions that have a generally self-limited course, in the periocular region, they have the potential to cause amblyopia, strabismus, and severe disfigurement. The decision for treatment can be a source of anxiety for patients, parents, and physicians alike. There are numerous treatment modalities, including emerging therapies that may make treatment safer and more effective than ever before. This review discusses our current understanding of this disease, its management, and future therapies.

Refractive and structural changes in infantile periocular capillary haemangioma treated with propranolol

PURPOSE

To evaluate the optical and anatomical effects of oral propranolol treatment for infantile periocular capillary haemangioma.

METHODS

All children diagnosed with infantile capillary haemangioma in 2008-2010 at a tertiary paediatric medical centre underwent comprehensive evaluation, including imaging, by a multidisciplinary team followed by oral propranolol treatment. Clinical follow-up was performed regularly until the lesions disappeared. Main outcome measures included changes in anatomical extraocular extension, refractive sphere and cylindrical power, and spherical equivalent in the involved eye before and after treatment and between the two eyes.

RESULTS

A total of 30 patients (8 male; mean age at diagnosis, 1.6±2.8 months) participated. The lesions affected the left eye in 53.3% and were located preseptally in 83.3%. Four patients (13.3%) received steroids before propranolol. A treatment dosage of 2 mg/kg per day was started at mean age 5.0±4.5 months, 3.3±4.3 months from disease onset. Side effects occurred in 11 patients and warranted a dose reduction (to 1 mg/kg per day) in 3 and treatment termination in 1. Findings were significant for mean reduction in involved extraocular area (P<0.0001), post-treatment reduction in mean cylindrical power in involved eyes (P=0.02), pre- and post-treatment differences in mean cylindrical power between involved and uninvolved eyes (P=0.02 and P=0.01, respectively), and post-treatment change in absolute values of mean spherical power between involved and uninvolved eyes (P=0.025).

CONCLUSIONS

Early diagnosis of infantile periocular capillary haemangioma and prompt treatment with propranolol lead to a significant reduction in the involved ocular area, in astigmatism, and prevent ocular/facial disfiguration/deformation, without rebound. Propranolol is recommended as the preferred treatment compared with other accepted therapies.

The role of surgical treatment in orbital vascular anomalies

BACKGROUND

The details of the surgical treatment of orbital vascular anomalies (OVAs) are not fully defined in the literature.

METHODS

Two hundred forty-nine patients who underwent surgical treatment of OVAs at our institution between January 1995 and December 2005 were included in a consecutive-series study. Each patient's clinical data, technique details, and clinical outcomes were prospectively collected. The aesthetic results were analyzed according to clinical features and treatment by using the χ (2) association test or Fisher's exact test.

RESULTS

Thirty-seven percent of the patients had OVAs involving the upper eyelid, 23% the lower lid, and 40% both eyelids. A complete resection was performed in 65.9% of the patients. A total of 379 surgeries were performed to achieve the final result. The majority of patients (98.3%) had no complaints about surgical scars. The majority of patients had no clinical treatment prior to the surgery. One or more clinical deformities were identified in association with the OVA. Those deformities included ptosis, scar sequelae due to ulceration/infection, eyelash or tarsal/ligament distortions, fibroadipose tissue residues, proptosis, or strabism. Bone deformities were present in 11.3% of the patients. A complete functional and aesthetic restoration was achieved in 66.6% of the patients.

CONCLUSIONS

Outcomes with a significant relationship to not obtain complete functional and aesthetic restoration included involvement of both eyelids, upper-eyelid involvement, older age, bilateral involvement, diffuse facial pattern OVAs, and OVAs with dimensions greater than one third of the orbit dimension.

Nonselective β-blocker propranolol for orbital and periorbital hemangiomas in infants: a new first-line of treatment?

Purpose

To determine the effectiveness and possible side effects of using propranolol for the treatment of orbital and periorbital infantile hemangiomas.

Methods

Infants with periorbital or orbital hemangiomas who had not received either local or systemic corticosteroids were recruited. The changes in tumor size, color, and texture, and any side effects of the drug were recorded.

Results

Fifteen infants with a mean age of 8.13 ± 4.7 months were treated according to the set protocol. A change in the color and texture of the hemangioma occurred in the first week following treatment. Mean duration of treatment was 7.67 ± 3.96 months. The size of hemangiomas decreased from a mean of 2.4 ± 0.9 cm to a mean of 1.6 ± 1.0 cm 3 months after treatment (P = 0.001). One patient had to stop the drug because of peripheral vascular ischemia. Another case had the dose reduced to control a mild hyperglycemia. Serious side effects were not observed. A single case of tumor regrowth (8.3%) was recorded.

Conclusion

Treatment of 1–2 mg/kg/day propranolol proved to be effective and associated with minimal side effects. It is likely to replace steroids as the first-line of treatment of hemangiomas in infants.

New developments in the management of periocular capillary hemangioma in children

The authors describe the theories of pathogenesis for capillary hemangioma and discuss the benefits and side effects of current treatment options, such as systemic and intralesional corticosteroids, laser therapy, and surgical excision. They also evaluate the recent systemic and topical applications of beta-blockers to treat infantile hemangioma. Although no major adverse events from beta-blocker treatment have been reported, the incidence of potential side effects such as bronchospasm, hypoglycemia, heart block, bradycardia, and congestive heart failure is unknown due to the novelty of the treatment. It has been postulated that topical application for localized superficial tumor may reduce systemic effects. Further research is necessary to compare the effectiveness of different treatments and to find the optimal dosing and delivery methods to minimize adverse effects in the treatment of this disorder.

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.

Periocular capillary hemangiomas: indications and options for treatment

Capillary hemangiomas are the most common periocular and orbital tumors of childhood that typically arise in infancy. Though the diagnosis is frequently made on clinical examination, various diagnostic modalities may be helpful in initial evaluation and follow-up. Tests may be necessary in diagnosing suspect cases or aid in the differentiation of potential malignant tumors. In the vast majority of cases these tumors undergo spontaneous involution without sequelae. However, some periocular and orbital capillary hemangiomas require intervention to prevent serious complications. Other tumors require treatment to lessen the surgical burden for cosmetic repair. When treatment is necessary, there are a number of therapeutic options available. As there is no standard, potential risks and benefits must be discussed with the family and treatment should be specific in each case. A complete understanding of the natural history of the tumor, indications for treatment, and response to different therapies is imperative in managing this common lesion.

Prevalence of amblyopia risk factors in congenital nasolacrimal duct obstruction

PURPOSE

To determine whether children who present to an ophthalmology practice for nasolacrimal duct obstruction are more likely to have risk factors for amblyopia.

METHODS

A retrospective chart review was conducted on all patients presenting to a pediatric oculoplastic specialist between January 1, 2001, and August 8, 2009. The review yielded 402 pediatric patients diagnosed with nasolacrimal duct obstruction. Children were classified as having amblyopia risk factors on the basis of the American Association for Pediatric Ophthalmology and Strabismus referral criteria.

RESULTS

Of 402 patients with nasolacrimal duct obstruction, 100% received a cyclopegic refraction. Of these, 88 patients (22%) were found to have amblyogenic risk factors; 65 of these patients had amblyogenic refractive errors, 9 had strabismus, and 14 had a combination of the two. Of the 88 patients with amblyopia risk factors, 11% had a family history of strabismus compared with 9% of patients without amblyopia risk factors, which was not a statistically significant difference. There was no other significant pathology found on the dilated fundus examinations except for one child known to have persistent hyperplastic primary vitreous and a congenital cataract and one child with previously known CHARGE syndrome before the examination for nasolacrimal duct obstruction.

CONCLUSIONS

Children who present with nasolacromal duct obstructions seem to be more likely to have amblyopia risk factors and therefore should have a full comprehensive pediatric ophthalmological examination, including cycloplegic refraction.

Relationship of infantile periocular hemangioma depth to growth and regression pattern

PURPOSE

Most infantile periocular hemangiomas undergo rapid growth in the first year of life, followed by gradual resolution over years. Treatment is indicated if vision is compromised and is usually continued through the growth phase. The objective of this study was to determine which clinical characteristics might aid in the prediction of growth and/or regression patterns of periocular hemangiomas.

METHODS

Retrospective review of medical records and photographs of children with periocular hemangiomas presenting to a UK pediatric eye unit over a 7-year period. Age at presentation, growth pattern, size, location, amblyopia, and refractive status were documented.

RESULTS

Forty-two infants with periocular hemangiomas were evaluated between 2000 and 2007, with a mean follow-up of 24 months (range, 6 months to 5 years). One-third (n=14, 33%) of the hemangiomas were superficial (strawberry nevi); one-third were subcutaneous (n=13, 31%), and the remainder were mixed (n=8, 19%) and orbital (n=7, 17%). There was a marked difference between the growth patterns of superficial (strawberry nevi) and deeper hemangiomas (orbital and subcutaneous), with a more prolonged period of growth noted in the deeper hemangiomas.

CONCLUSIONS

Periocular hemangiomas with a deep component tend to have a later onset and prolonged period of growth compared to strawberry nevi. Clinically evident depth of the hemangioma appears to be a valuable predictor of rapidity of resolution. This finding may be useful in assessing prognosis and planning treatment of infantile periocular hemangiomas.

Sub-Tenon's Steroid Irrigation for Treatment of Intraorbital Capillary Hemangioma

SUMMARY

A four-month-old male infant underwent sub-Tenon's steroid irrigation for treatment of orbital capilary hemangioma that was causing exposure keratopathy risk to the left eye from progressive proptosis. The temporal inferior sub-Tenon's space was irrigated with a mixture of triamcinolone acetonide (40 mg/ml) and betamethasone sodium phosphate (6 mg/ml) by a blunt-tipped sub-Tenon's cannula. We describe this procedure as irrigation because reflux of the mixture from the incision was permitted. Two weeks after treatment, a marked reduction of proptosis was noted. One month after treatment, the volume of the intraorbital hemangioma resolved significantly in MRI examination. Steroid treatment can be applied local or systemically to treat orbital capillary hemangioma but side effects must be considered carefully. Sub-Tenon's steroid irrigation may be a benefical, effective, pratical and safe application route in the treatment of orbital capillary hemangiomas.

Treatment of capillary hemangiomas causing refractive and occlusional amblyopia

PURPOSE

Capillary hemangiomas of the eyelid and orbit are treated when amblyopia secondary to anisometropic astigmatism or pupillary occlusion is present or when rapid growth of the hemangioma threatens to occlude the pupil. The goal of this study was to determine whether treatment of hemangiomas resolves or prevents occlusion or results in decrease in astigmatism.

METHODS

The records of 54 patients who underwent treatment for reduction in the size of a capillary hemangioma causing amblyopia or threatened amblyopia in two pediatric ophthalmology practices were reviewed.

RESULTS

Twenty-eight patients were treated for amblyopia due to anisometropic astigmatism. The average amount of pretreatment astigmatism was 2.71 D, while the average amount of post-treatment astigmatism was 0.46 D. Fifteen of these patients could be tested for optotype visual acuity and all had vision acuity of 20/40 or better. Only 1 of the 15 patients treated for threatened occlusion of the pupil developed occlusion. Six of these patients cooperated with optotype visual acuity and all had vision acuity of 20/30 or better. Eleven patients were treated for pupillary occlusion. Occlusion resolved in all cases. Of the five patients treated for occlusion who cooperated with optotype visual acuity, two had a vision acuity of 20/100 or worse.

CONCLUSIONS

Treatment to reduce the size of capillary hemangiomas results in resolution of occlusion, reduction in astigmatism, and prevention of pupillary occlusion. Those with occlusion are at higher risk for severe residual amblyopia and require prompt and definitive treatment.

Developmental abnormalities of the optic nerve and chiasm

Developmental anomalies of the optic nerve are an important and growing cause of lifelong visual handicap and they are often associated with systemic abnormalities. This review focuses on the ocular and systemic aspects of developmental anomalies arising from defects of fetal fissure closure and retinal ganglion cell development, and covers some other optic-disc anomalies that have systemic significance.

Reappraisal of astigmatism induced by periocular capillary hemangioma and treatment with intralesional corticosteroid injection

OBJECTIVE

To document refractive status and visual acuity before and after intralesional corticosteroid injection in children with astigmatism induced by periocular capillary hemangioma (PCH).

DESIGN

Retrospective, interocular comparison, interventional case series.

PARTICIPANTS

Thirteen infants with anisometropic astigmatism of at least 1.50 diopters (D) induced by PCH.

INTERVENTION

All infants had one or more intralesional corticosteroid injections of a PCH between 2 and 10 months of age. Injections of 0.3 to 1.0 ml of a 50:50 mixture of triamcinolone (40 mg/ml) and dexamethasone phosphate (4 mg/ml) were given at a single site under deep sedation.

MAIN OUTCOME MEASURES

Refraction and acuity using Teller acuity cards before and after injection.

RESULTS

In affected eyes, mean astigmatisms were 3.75 D (pretreatment) and 1.25 D (posttreatment), and mean spherical errors were 0.75 D (pretreatment) and 1.50 D (posttreatment). Reduction in astigmatism was observed within 1 to 14 months after the injection. Despite reciprocal changes in astigmatism and spherical error, the amount of anisometropia (spherical equivalent) remained constant. Amblyopia was not observed before treatment and was observed in only 2 of 13 children after treatment. Complications were limited to adrenal suppression with transient reductions of linear growth and localized eyelid necrosis.

CONCLUSIONS

Intralesional corticosteroid injections given in infancy (between 2 and 10 months) resulted in a 63% reduction in the mean amount of astigmatism induced by PCH. The reciprocal changes of astigmatism and spherical error without changes in anisometropia suggest that the treatment effect was due to restoration of the spherical shape of the cornea. Before 3 years of age, visual immaturity exceeded the optical blur related to astigmatism induced by PCH. Therefore, astigmatism, not anisometropia or amblyopia, is the immediate indication for treatment of PCH with intralesional corticosteroids. Injection of corticosteroid at a single site minimizes the potential for severe ocular complications owing to tissue pressure and tumor volume considerations.