Corticosteroid treatment of periorbital haemangioma of infancy: a review of the evidence

[Treatment and management of orbital tumors]

BACKGROUND

There are various options for the conservative treatment of the most frequent orbital tumors. These can delay, complement or be superior to the surgical approach, which is often prone to complications.

OBJECTIVE

This article gives a summary of the possible treatment options for the most common orbital tumors in childhood and adulthood.

METHODS

A literature search was carried out and the possible treatment pathways are presented.

RESULTS

1. Frequent orbital tumors in childhood: a systemic treatment with noncardioselective beta blockers is the primary treatment for capillary orbital hemangiomas. In cases of no response, steroids, interferon alpha or cyclophosphamide are treatment options. Observation is a possible option for smaller dermoid cysts, in cases of progression excision can become necessary. Symptomatic optic nerve gliomas can also be observed and in cases of progression treated with chemotherapy, mTOR/MEK inhibitors or radiotherapy (children > 5 years). Rhabdomyosarcomas are biopsied and subsequently treated by radiotherapy and chemotherapy. 2. Frequent orbital tumors in adulthood: asymptomatic cases of cavernous hemangiomas of the orbit can just be observed. Symptomatic hemangiomas can be surgically excised or treated with radiotherapy. For meningiomas of the optic nerve sheath radiotherapy is a very effective treatment. Surgical excision should be reserved for cases with no prognosis of visual acuity. There is also the option to treat with antiprogesterone. Orbital lymphomas with purely orbital involvement can be treated with radiotherapy, chemotherapy or the application of rituximab.

CONCLUSION

There are now very effective conservative treatment options for many orbital tumors. In some cases a surgical procedure can be avoided and a good visual function can be retained.

Subcutaneous hemangioma on nasal dorsum: a case report

INTRODUCTION

Hemangioma is a benign tumor made up of blood vessels and typically occurs as a slightly elevated purplish or reddish area of skin. Hemangioma is mostly found superficially; subcutaneous hemangioma in the nasal dorsum is rare.

CASE PRESENTATION

In West Nusa Tenggara Regional Hospital, the authors found two cases of subcutaneous hemangioma in patients of very different ages. The first patient was a 2-year-old Sasak girl, and the other was a 40-year-old Sasak man. The pediatric patient was treated with an elliptical approach, whereas the adult patient was treated with lateral rhinotomy extended by an elliptical approach to remove the hemangioma and ligate the feeding arteries. After surgery, the adult patient was followed up for 5 months, whereas the pediatric patient was followed up for 3 months. The results for both patients were good, with minimal scar formation.

CONCLUSION

Despite the limitations of technology and human resources in a remote area of Indonesia, the surgical approach used in these cases produced good outcomes for both patients.

Kasabach-Merritt syndrome combined with hypercalcemia: A case report

The present case report presented the diagnosis and treatment course of an infant diagnosed with Kasabach-Merritt syndrome (KMS) combined with hypercalcemia (HC). A 35-day-old infant with swelling on the upper right arm for >1 month and thrombocytopenia for 1 day was admitted to Hunan Provincial People's Hospital (Changsha, China) and a series of treatments, including γ-globulin impact, heparin anticoagulation, platelet transfusion, supplement of cryoprecipitate and fibrinogen following heparinization and inhabitation of vascular endothelial cell proliferation by propranolol, were performed. At 2 months after the initial admission to the hospital, surgery was conducted and the hemangioma was removed through pipeline arteriosclerosis embolization when the patient was hospitalized again with symptoms of vomiting and atrophy accompanied by HC. The level of blood calcium reduced to normal following surgery. Cases of KMS combined with HC are extremely rare and the most effective way to treat such cases is surgical resection of the hemangioma.

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.

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.

Management of periorbital hemangioma by intralesional glucocorticoids and systemic propranolol: a single-center retrospective study

Periorbital hemangioma may lead to the vision impairment so effective treatment should be adopted in time. In this study, we made a retrospective analysis of intralesional glucocorticoids and systemic propranolol in the management of periorbital hemangioma. From Jan. 2006 to Dec. 2013, twenty-five children with periorbital hemangioma were enrolled into this study. Among them, sixteen children accepted intralesional injection of compound betamethasone preparation. Eight children accepted systemic propranolol. One child accepted both of the two treatments. The follow-up period ranged from 6 months to 60 months. The results showed that in the patients with intralesional compound betamethasone preparation, 13/16 patients' tumors involuted completely. 3/16 patients' tumors didn't involute completely at the end of follow-up. In the patients with systemic propranolol, 8/8 patients' tumors involuted almost completely. One patient didn't respond to intralesional glucocorticoids, and so switched to systemic propranolol, which lead to the involution of tumor finally. The adverse effects in the patients with intralesional glucocorticoids included local soft tissue atrophy, local ulcer, and Cushing-like manifestations, which occurred in three patients respectively. In the patients with systemic propranolol, mild diarrhoea occurred in one child. According to our observation, both of intralesional glucocorticoids and systemic propranolol achieved good results in the management of periorbital hemangioma. Systemic propranolol showed superiority in efficacy and safety. We recommend systemic propranolol as the first-line therapy. However, for the children who can't tolerate systemic propranolol, intralesional glucocorticoids still is a feasible choice.

Comparison of intralesional corticosteroid and propranolol treatment of periorbital infantile hemangiomas: an outcome study of 61 cases

PURPOSE

To compare intralesional corticosteroid (IC) injections with oral propranolol in children with periorbital infantile hemangioma (IH).

METHODS

Children were diagnosed with IH and treated with IC (n = 29) or propranolol (n = 14). In cases in which no further improvement was seen, treatment was stopped and the outcome measured. Type, duration, and complications of treatment and supportive or additional therapies were scored, along with outcomes of visual measurements, at the start and end of therapy.

RESULTS

Twenty-one of the 29 children (72%) treated with IC injections were given a second injection and 16 (55%) were given more than two. Median duration of IC therapy was 15.9 months (interquartile range (IQR) 10.28), compared with 6.5 months (IQR 4.87) for propranolol (p<0.001). The complications reported after IC injections were bleeding (n = 9) and ulceration (n = 7). No complications were noted in the propranolol group. Additional therapy consisting of oral prednisolone therapy was applied in one child from the steroid-treated group. The levels of amblyopia and the median absolute improvement did not significantly differ between the groups.

CONCLUSIONS

The IC injections and oral propranolol medication equally improved amblyopia in children with IH of the periorbital and cheek region; however, propranolol was associated with fewer complications and additional or supportive treatment was not indicated. We prefer oral propranolol medication over IC injections in cases in which IH threatens to hamper visual acuity.

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.

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.

Haemangioma: clinical course, complications and management

Despite their high incidence, most infantile haemangiomas (IH) do not require treatment as they regress spontaneously and most do not leave significant sequelae. For the subset of haemangiomas that require treatment, indications for intervention can be divided into three main categories: ulceration, disfigurement and impairment of function or vital structures. In addition, certain IH have a risk of associated structural anomalies. Given the wide heterogeneity of haemangiomas, deciding which haemangiomas need intervention and when to intervene requires a detailed knowledge of natural history and clinical indicators of increased risk.

Beta-blockers versus corticosteroids in the treatment of infantile hemangioma: an evidence-based systematic review

BACKGROUND

The efficacy and safety of beta-blockers versus corticosteroids in the treatment of infantile hemangiomas (IHs) is controversial. This study aimed to summarize evidence described in the literature and to assess the quality of studies involving beta-blockers and corticosteroids for the treatment of cutaneous IHs.

METHODS

Comparative studies were collected from 15 online electronic databases, including OVID Medline, PubMed, ISI Web of Science, CENTRAL, CNKI, ChiCTR, JPCTR, CTRIndia, IranCTR, SLCTR, ISRCTRN, NLCTR, GCTR, ANCTR, ClinicalTrial. gov, and associated references. Studies without a control group were excluded, and the remaining studies were assessed by two reviewers independently using the Downs & Black scale for reported quality. The main areas assessed in the included studies were volume changes, overall improvement in appearance, eye function, and adverse events.

RESULTS

Ten comparative studies were included with a total of 419 children. A meta-analysis was not performed due to the considerable heterogeneity across studies. Some evidence showed that beta-blockers are superior to steroids in reducing volume and improving the overall appearance of IHs, such as lightening of the color and flattening of the surface. Conclusions regarding improved eye function and adverse events were divided, and no consensus has been reached on the superiority of one treatment over another. No episodes of severe-onset asthma, hypotension, or bradycardia occurred in the beta-blocker treatment due to the rigorous exclusion of patients with contraindications.

CONCLUSIONS

Available studies indicate that beta-blockers are an alternative option to corticosteroids for IH treatment with respect to volume shrinkage and improvement in appearance. No evidence has shown a significant difference in improved eye function and adverse events between beta-blockers and corticosteroids in the treatment of IH; indeed, there is a lack of well-designed, high-quality randomized control trials.

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.

Oral propranolol for the treatment of periorbital infantile hemangioma: a preliminary report from oman

Purpose:

To investigate the efficacy and safety of oral propranolol in the management of periorbital infantile hemangioma in four subjects.

Materials and Methods:

Consecutive patients who presented with periorbital capillary hemangioma with vision-threatening lesions were prospectively enrolled in this study between January 2009 and October 2010. All subjects underwent treatment with 2 mg/kg/day oral propranolol. All subjects underwent ocular, systemic, and radiologic evaluations before treatment and at periodic intervals after starting therapy. Side effects from therapy were also evaluated.

Results:

Four subjects, between 3 months and 19 months of age, with periorbital hemangioma were enrolled in this study. Two subjects had been previously treated with oral corticosteroids with unsatisfactory response. All subjects had severe ptosis, with the potential for deprivation amblyopia. Three subjects had orbital involvement. After hospital admission, oral propranolol was initiated in all subjects under monitoring by a pediatric cardiologist. Subsequent therapy was performed with periodic out-patient monitoring. All subjects had excellent response to treatment, with regression of periorbital and orbital hemangioma. There were no side effects from therapy.

Conclusions:

Oral propranolol for periorbital hemangioma was effective in all the four subjects. Oral propranolol may be appropriate for patients who are nonresponsive to intralesional or systemic steroids. In patients with significant orbital involvement and lesions causing vision-threatening complications, oral propranolol can be the primary therapy.

Topical propranolol therapy for infantile hemangiomas

The nonselective beta-adrenergic receptor antagonist propranolol is an effective therapy for infantile hemangiomas. Systemic propranolol therapy shows a rapid therapeutic effect with good drug tolerability. We report on the efficacy of local application of propranolol ointment in superficial hemangiomas of the skin. In our outpatient department, 45 children with 65 hemangiomas were treated with 1% propranolol in a hydrophilic ointment topically applied twice a day. Before start of treatment and at each visit, clinical photographs were taken. If ultrasound did not confirm occult deeper components, children were included in the study. Treatment in the proliferative phase within the first 6 months of life (including seven preterm infants) induced regression in 59% and cessation of growth in 26% of the hemangiomas. No response or proliferation of subcutaneous components was observed in 15%. Clinically, no side effects caused by the beta-receptor blocker were noticed. Treatment of two ulcerated hemangiomas of the perineal region twice using a flash lamp pulsed-dye laser and propranolol ointment in the surrounding lesion led to healing of the ulcers in 3 and 6 weeks, respectively. In six patients, topical therapy was started between the ages of 7 and 33 months. Even in these hemangiomas, improvement was obvious after 2 or 3 months. Propranolol administered topically in 1% ointment could have a beneficial effect on superficial hemangiomas of the skin. The treatment was well tolerated without side effects even in preterm infants and in children with numerous or large lesions.

Periorbital hemangiomas: the need for active management - report of two cases

Hemangioma is the most common tumor of childhood and is commonly located on the head or neck. The orbit is often affected and early and aggressive intervention is required to prevent serious visual complications. This paper reports on two cases. In the first case, the patient's vision was impaired, while in the second case a deep hemangioma affecting adjacent areas was confirmed radiologically. Treatment with aggressive systemic corticotherapy was successful, thus avoiding permanent damage to the patients' vision. Furthermore, esthetic outcome was satisfactory. The treatment of choice is oral corticosteroids and management should be individualized and should include careful follow-up to monitor possible adverse effects.

Clinical review of periorbital capillary hemangioma of infancy

PURPOSE

To explore the role of intralesional steroid injections (ILSI) and oral steroids in the management of periocular hemangioma of infancy (HOI).

METHODS

In this retrospective study, treatment options studied were observation, ILSI, and oral steroids. All children received adjunctive amblyopia treatment if required. The main indications for treatment were cosmetic, worsening astigmatism, and visual axis obscuration. Success was defined as complete HOI regression before the age of 5 years (cosmetic group), reduction of astigmatism of at least 1 diopter cylinder (DC) (astigmatism group), or no evidence of amblyopia at the last follow-up (visual axis obscuration group).

RESULTS

Twenty-four of 41 children (58.5%) had amblyopia at presentation. Eighteen children formed the observation group, 17 children received ILSI, and 6 children received oral steroids. Successful outcome was achieved in all except 2 patients in the cosmetic group and 6 of 7 in the visual axis obscuration group. Mean astigmatic correction of all cases was 1.65 ± 1.34 DC before treatment and 0.91 ± 1.17 DC after treatment, the change being statistically significant (P < .001).

CONCLUSION

Observation appears to be a highly effective strategy if coupled with amblyopia therapy, especially for mild cases. Intralesional and oral steroids appear to be equally effective for lesions requiring treatment, but their exact role cannot be clearly determined in the presence of a spontaneously resolving lesion.

Scoring the proliferative activity of haemangioma of infancy: the Haemangioma Activity Score (HAS)

BACKGROUND

Haemangioma of infancy (HOI) is the most frequently occurring benign tumour of infancy. A good, reliable and objective scoring system for haemangioma activity is not yet available.

AIM

We have developed a simple system called the Haemangioma Activity Score (HAS) for scoring the (disease) proliferative activity of haemangiomas. The current study was undertaken to validate this system.

METHODS

We validated the HAS in a comparative study of photographs taken during consultations from 2000 until 2008 (n = 78). Agreement between three observers was assessed at two different time points (t(0) and t(1)) with a minimum interval of 6 months between them, using interclass correlation coefficients (ICC).

RESULTS

Agreement between observers was good. The average ICC of the HAS at t(0) and t(1) was 0.72 and 0.76, respectively. The average ICC of the HAS for the changes from baseline (HAS at t(0) minus HAS at t(1) ) was 0.69.

CONCLUSIONS

We conclude that the HAS is a good system for scoring the proliferative activity of haemangiomas, and believe it to be useful in future investigations. The number of studies comparing different therapies for treating haemangiomas is steadily increasing, and the HAS (before and after treatment) may provide a valuable scoring system for evaluating such therapies.

Visual outcomes of treated periocular capillary haemangiomas in childhood: a 10-year review

PURPOSE

To report our experiences of treating periocular capillary haemangioma with particular emphasis on visual outcomes.

METHODS

Patients who underwent treatment for periocular capillary haemangioma were identified, and a chart review was performed.

RESULTS

There were seventeen patients in the study. The main indications for treatment were increased size of lesion with threat of amblyopia and partial or full pupil occlusion. Seven patients required more than one type of treatment. Fourteen patients had intralesional steroid treatment and six patients had oral steroids. Intralesional steroids gave variable results with minimal side-effects, oral steroids were very effective but 4 out of 6 patients developed side-effects. The average pretreatment astigmatism was 2.4D and post treatment this had reduced to 1.3D. Final visual outcomes were available for 15 patients, 13 had visual acuity of 6/7.5 or better, two were amblyopic with vision of 6/9-2 and 6/18.

CONCLUSION

In this study, intralesional steroids were used for localized lesions and oral steroids for diffuse haemangiomas with orbital involvement. Treatment especially with oral steroids was found to halt the proliferative phase and assist early haemangioma regression reducing ocular sequelae.

Current management of infantile hemangiomas

During the past several years, there have been new advancements in the management of infantile hemangiomas (IHs). In many patients, no treatment is ever necessary--because IHs are well known for their natural history of spontaneous involution. However, a significant minority of hemangiomas do require treatment. Moreover, they are very heterogeneous, making the decision of when, how, and why to intervene quite variable. The least common but most important rationale for intervention is the presence of a life- or function-threatening complication, where prompt therapeutic intervention is a necessity. A much more common scenario is ulceration, where appropriate management is needed to expedite healing and control pain. Increasingly, the life-altering aspects of hemangioma are being recognized as a rationale for treatment because permanent scarring and disfigurement can result even if involution is complete. Treatments for IHs currently include topical, intralesional, and systemic therapies. Laser and surgical modalities are also sometimes used depending on the clinical scenario. In the absence of rigorous evidence-based studies, clinicians must carefully weigh the risks and benefits of medical or surgical treatments versus observation alone in tailoring management to the specific clinical situation at hand.

Abordagem terapêutica dos hemangiomas cutâneos na infância

FUNDAMENTOS: Hemangioma é um tumor benigno de células endoteliais comum na infância e de involução espontânea. OBJETIVO: Avaliar os tratamentos utilizados em 122 pacientes com hemangiomas cutâneos, tratados no Hospital Universitário de Brasília, de março de 2000 a dezembro de 2006. MÉTODOS: Utilizou-se coleta de dados em prontuários e aplicação de questionários aos pais. Foram analisados gênero, fatores pré-natais e perinatais, características clínicas, tipo de tratamento e resultados. RESULTADOS: A razão de sexo (F: M) foi de 1,5:1. 42, em pacientes que apresentavam hemangiomas superficiais, 13 profundos e 67 mistos; em 7 pacientes, havia associação com síndromes. Em 79 pacientes, localizavam-se no polo cefálico. Já em 98/122 dos pacientes, foram submetidos a tratamento único e 24/122 a múltiplos. No primeiro grupo, foi utilizada conduta expectante em 38 pacientes, compressão em 3, corticoide sistêmico em 18, corticoide intralesional em 13, corticoide tópico em 4, cirurgia convencional em 12, criocirurgia em 7, luz pulsada em 1 e imiquimod em 2. No segundo grupo, 15 fizeram 2 tipos de tratamentos e 9 necessitaram de 3 ou mais tratamentos. CONCLUSÃO: Os dados obtidos concordam com a literatura mundial, quanto a sexo e localização da lesão. A incidência de hemangiomas presentes ao nascimento foi maior que em outras publicações. Os resultados terapêuticos obtidos foram comparáveis aos publicados na literatura. A identificação dos hemangiomas que necessitam de tratamento, em que momento adequado para intervenção e a melhor opção terapêutica devem ser considerados.

Intralesional and sub-Tenon's infusion of corticosteroids for treatment of refractory periorbital and orbital capillary haemangioma

PURPOSE

To evaluate the effect of combined intralesional and sub-Tenon's administration of corticosteroids for the treatment of refractory periocular and orbital capillary haemangioma in a retrospective, non-comparative study.

METHODS

Seven infants with resistant periorbital and orbital capillary haemangioma who attended our tertiary centre from 2000 to 2005 were treated with an intralesional injection of a mixture of betamethasone 6 mg/cc and triamcinolone 10 mg/cc, by body weight, together with sub-Tenon's infusion of betamethasone 6 mg/cc and triamcinolone 40 mg/cc of a volume of 1 cc, close to the orbital lesion, in the same session. Visual axis, proptosis, pre- and post-treatment changes in four refractive parameters, and parental satisfaction were evaluated.

RESULTS

None of the babies had proptosis or visual axis obstruction after treatment. Mean spherical power decreased by 22.7% (P=0.06). Mean spherical equivalent decreased in 34%, but the difference was not statistically significant (P=0.09). No early or late ocular side effects were observed. Mean intraocular pressure results were normal before and immediately after treatment, and during the follow-up period. Parental satisfaction score during follow-up was 9/10. Mean time to improvement was 96.43+/-58.3 days.

CONCLUSIONS

Combined local corticosteroid administration by posterior sub-Tenon's infusion and intralesional injection in babies with extensive capillary haemangioma is associated with a satisfactory anatomical and functional outcome and there were no ophthalmic side effects.

The effect of intralesional steroid injections on the volume and blood flow in periocular capillary haemangiomas

AIM

To examine the effect of steroid therapy on the volume estimates and blood flow characteristics of childhood periorbital capillary haemangiomas.

PATIENTS AND METHODS

Children at risk of amblyopia due to periorbital haemangiomas were treated with intralesional steroid injections (between 1 and 4 courses) and serial assessment of the volume and blood-flow characteristics of the lesions measured using colour Doppler ultrasonography. The characteristics of the haemangiomas in these children were compared with a cohort of untreated cases.

RESULTS

Eight of nine treated children were female, this proportion being significantly different from the equal sex distribution of an untreated cohort (p < 0.05). All children in the steroid-treated group presented within 1 month of birth, compared to the untreated children, who presented at an average of 2.1 months of age (range 0-14, median 2.9 months) (p = 0.04) and they required significantly longer follow-up in the Orbital service (mean 65 months, range 26-105), compared with an average of 35 months (range 4-92, median 23) in the untreated group (p = 0.002). The maximum estimated volume of the lesions were significantly larger in the treated group (treated group mean 8.9 ml, untreated group mean 4.1 ml; p = 0.016), with a trend towards higher maximum measured blood velocities in the treated group (treated mean 64 cm compared with untreated mean 52 cm; p = 0.1). Steroid injections appear to reduce the volume and blood flow of haemangiomas, this suppression persisting for several months (between 5 and 20) before the lesion later displays the cyclic fluctuations in volume and flow seen with untreated lesions. All treated haemangiomas had some residual vascular anomaly, detectable on ultrasonography, at last follow-up--this being despite absence of clinical signs in most cases.

CONCLUSION

Periorbital capillary haemangiomas requiring steroid therapy for risk of amblyopia were significantly commoner in females, were larger lesions and presented at an earlier age. Intralesional steroids appear to cause a reduction of blood flow, with a transient reduction in volume and a suppression of the natural cyclic variation seen without treatment. The changes after a course of steroid therapy appear to last for between 5 and 20 months, this period of suppression of the lesion probably being particularly useful during infancy and early childhood when the child is at greatest risk of amblyopia.

Combined surgical method of orbital and periorbital hemangioma treatment in infants

PURPOSE

To analyze the results of application of combined surgical treatment in different forms of hemangioma in infants.

MATERIALS AND METHODS

One hundred seventy-four children with different forms of orbital and periorbital hemangiomas aged 1-16 months (mean age 5.2 + 1.97 months) were operated on at the pediatric ophthalmology department. Fast growth of hemangioma, both superficial (intradermal) and deep (subdermal and orbital) localization, significant deformity of eyelids, with narrowing of eye fissure were the indications for surgical treatment. The combined-staged method, including cryosurgery of superficial intradermal lesions and surgical excision of subdermal and/or orbital parts of the tumor in different combinations depending on the form and depth of hemangioma spreading, was applied.

RESULTS

Usage of cryodestruction usually on the first stage of treatment allowed gentle scarring of the angiomatously changed skin areas. Surgical excision of the deep part of the tumor eliminated disfigurement and visual axis occlusion, avoiding amblyopia development. Good cosmetic and anatomic result was achieved in 90.4% of cases.

CONCLUSION

Combined surgical method of treatment of progressive capillary hemangiomas by using cryosurgery and surgical excision in infants allows the choice of optimum tactics depending on features of the course and clinical picture in each individual case and provides achievement of high cosmetic and functional result of treatment. The early beginning of treatment in cases of fast progressing of the tumor allows prevention of extensive skin affection and amblyopia development.

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.

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.

Surgical treatment of capillary hemangiomas causing amblyopia

BACKGROUND

Capillary hemangiomas of the eyelids and orbit can cause refractive and occlusive amblyopia. Although oral and intralesional steroid injections are the most common treatment modalities, sometimes they are not successful. There is a paucity of information in the literature on the success of eliminating amblyogenic factors by treating these lesions with surgical resection.

METHODS

Retrospective chart review of 10 patients in two pediatric ophthalmology practices who underwent surgical excision of a capillary hemangioma that was causing amblyopia and that had failed to regress with other treatment.

RESULTS

Two patients had surgery secondary to pupillary occlusion, which was successful in relieving occlusion. Eight patients had surgery secondary to significant astigmatism. The average preoperative astigmatic difference between the affected and unaffected eye in five of these patients undergoing surgery before the age of 21 months was 2.15 D. The average postoperative astigmatic difference was 0.1 D. The average preoperative astigmatic difference between the affected and unaffected eye in three patients undergoing surgery after 21 months of age was 1.6 D. Surgery completely failed to reduce the astigmatism in two of these patients. The third patient had a decrease of 0.75 D of cylinder but still had a difference of 1.75 D between the two eyes postoperatively. Postoperative complications in this study included wound infection in one patient.

CONCLUSIONS

Surgical excision of capillary hemangiomas that were resistant to other modes of treatment was useful in relieving pupillary occlusion and in decreasing the amount of astigmatism if performed before the age of 21 months in our series of patients. Our cases as well as the literature suggest that surgery should be performed at 13 months or earlier to reduce the amount of astigmatism.