Periocular Capillary Hemangioma Research Articles

Periocular Capillary Hemangioma Treated With Low Dose Oral Propranolol - Presentation and Outcome of 2 patients

Introduction : Infantile hemangioma (IH) is the most common benign vascular tumor of infancy. IH arises in the first few weeks of life, then displays a period of active growth followed by spontaneous involution.[1,2] Most IHs are uncomplicated, do not require intervention, and regress spontaneously.[3] Infantile hemangioma (IH) having an incidence of 4%–5%.[4-6]
 Case Illustration : First patient is 6 -month-old girl weighing 6.2 kg, with Periocular lesions on the superior palpebra since 2 weeks after birth. Second patient is 6-month-old girl weighing 6.3 kg, with Periocular lesions on the superior palpebra since 1 weeks after birth. The lesions rapidly increased in size within 1 months. The lesions made it difficult to open superior palpebra. Both patient was diagnosed with periocular infantile hemangioma. The diagnosis was established by clinical examination, and was given oral propranolol therapy. Initially, a dose of propranolol was 1 mg/kg body weight in divided doses for 2 weeks then increased to 2 mg/kg body weight. Patients have followed up at 4-week intervals until the final follow-up was reached according to the response of treatment. The lesions were significantly decreased and bith pastients could open their right eye normally after 3 months of propranolol therapy
 Discussion : Some cases of IH require early treatment. Early treatment is indicated for IH causing functional impairment. The use of propranolol in the management of IH is very effective in the reduction of the lesions and Has minimal side effects.
 Conclusion : Early diagnosis and intervention with propranolol for IH play an important role in determining the optimal outcomes

Periocular Capillary Hemangioma Treated With Low Dose Oral Propranolol - Presentation and Outcome of 2 patients

Introduction : Infantile hemangioma (IH) is the most common benign vascular tumor of infancy. IH arises in the first few weeks of life, then displays a period of active growth followed by spontaneous involution.[1,2] Most IHs are uncomplicated, do not require intervention, and regress spontaneously.[3] Infantile hemangioma (IH) having an incidence of 4%–5%.[4-6]
 Case Illustration : First patient is 6 -month-old girl weighing 6.2 kg, with Periocular lesions on the superior palpebra since 2 weeks after birth. Second patient is 6-month-old girl weighing 6.3 kg, with Periocular lesions on the superior palpebra since 1 weeks after birth. The lesions rapidly increased in size within 1 months. The lesions made it difficult to open superior palpebra. Both patient was diagnosed with periocular infantile hemangioma. The diagnosis was established by clinical examination, and was given oral propranolol therapy. Initially, a dose of propranolol was 1 mg/kg body weight in divided doses for 2 weeks then increased to 2 mg/kg body weight. Patients have followed up at 4-week intervals until the final follow-up was reached according to the response of treatment. The lesions were significantly decreased and bith pastients could open their right eye normally after 3 months of propranolol therapy
 Discussion : Some cases of IH require early treatment. Early treatment is indicated for IH causing functional impairment. The use of propranolol in the management of IH is very effective in the reduction of the lesions and Has minimal side effects.
 Conclusion : Early diagnosis and intervention with propranolol for IH play an important role in determining the optimal outcomes

TIMOLOL IN CAPILLARY HEMANGIOMA IN INFANT

Background: The purpose of this study was to evaluate the effect of topical timolol in the management of periocular capillary hemangioma. Objective: Efficacy of Timolol in Capillary Hemangioma Methods: A prospective study was performed in 48 consecutive patients with periocularhemangioma. 24 patients underwent topical timolol and Next 24 patientreceived lubricating eye drops topical as a control group.The size of the lesion was measured serially every week during the first month, every 2 weeks for the second month, and then monthly for another 4 months. Therefractive statusand degree of ptosis if present were measured before and at the end of the study. Results: There was reduction in the size of hemangioma, astigmatic error, and degree of ptosisin both the groups. The difference in outcome between two groups was statistically significant. Rebound growth occurred in 22.22% of the group Using timolol and 37.51% of the control group. No adverse effects were reported during or after topical timolol. Conclusion: Topical timolol may have good efficacy fortreatment of infantile periocular hemangioma.

Treatment outcomes of oral propranolol in the treatment of periocular infantile capillary hemangioma and factors predictive of recurrence and incomplete resolution: A multi-centric study.

This study aims to evaluate the treatment outcomes of periocular capillary hemangioma with oral propranolol (OP) and list the factors predictive of recurrence and incomplete resolution after treatment. Data were collected by retrospective review of medical files of patients with infantile hemangioma (IH) treated with OP during January 2014-December 2019 from two tertiary eye institutes from India. Patients presenting with symptoms of IH with/without any history of prior treatment were included. All patients were started on OP with the dose of 2-2.5 mg/Kg body weight and continued till complete resolution or till the lesion reached a plateau response. Details about the ophthalmic examination at each visit and availability of imaging findings were noted down from the records. Primary outcome: Study the treatment outcome of patients treated with OP and discussed our observations regarding factors that may predict nonresponse, poor response, or recurrence. Secondary outcome: complications/side effects of therapy. Response to treatment was judged as fair, good, and excellent depending on resolution <50%, >50%, and complete resolution, respectively. Univariate analysis of factors related to treatment response was judged as fair, good, and excellent depending on resolution <50%, >50%, outcome and recurrence was studied using Mann-Whitney U test and Fisher's exact test. A total of 28 patients were included in the study, out of which 17 were female and 11 were male. The mean age of onset of the lesion was 1.08 (± 1.484) months, 11 being congenital in origin. The mean age at presentation was 4.15 (± 2.92) months. 46.43% (n = 13) of patients showed complete resolution, while 25% (n = 7) showed more than 50% reduction in lesion size. Fair response was noted in 28.57% (n = 8). The mean duration of follow-up after stopping OP was 17.7 (± 20.774) months. The recurrence rate noted was 14.28%. The factors which were associated with incomplete resolution were age at presentation >3 months, later age of appearance of the lesion, superficial lesions with no orbital involvement. Male gender and congenital lesions responded best to OP therapy. Minor complications were noted with a rate of 25% (n = 7). Younger age at presentation was more commonly associated with complications. OP is a safe and effective treatment for capillary hemangioma except for a smaller subset of patients who show suboptimal response to this drug. However, specific factors responsible for suboptimal response or recurrence after OP therapy remain elusive. Although not statistically significant, there was an increasing trend toward higher age at presentation, low birth weight, and superficial lesions with a poorer response. Furthermore, these factors along with the male gender were commonly associated with recurrence in our series. Larger prospective studies focused on evaluating clinical factors responsible for incomplete resolution and recurrence will help in prognosticating and suggesting alternative treatment regimes.

Periocular capillary hemangioma treated with low dose oral propranolol - presentation and outcome of 30 patients

Purpose: To evaluate the presentation and outcome of periocular capillary hemangioma treated with low-dose oral propranolol. Method: Thirty cases of periocular capillary hemangioma prospectively studied from 1st June 2015 to 31st May 2017 who received oral propranolol on an outpatient basis. Hemangioma causing any threat to vision or disfigurement was included and age below 3 months and multiple lesions were excluded. Starting dose of propranolol was 1 mg/kg and increased to 2 mg/kg after 2 weeks as a maintenance dose. The tapering dose was 1 mg/kg of body weight before discontinuing the medication. Treatment was continued till the child is 1 year of age or no further change in color or size of the lesion in two successive follow-ups. Results: Presenting age was 6.36 ± 3.36 months (ranged 3–24 months) with female predominance (70%). In 86.6% of cases, the vision was Central Steady and Maintained and cycloplegic refraction showed marked astigmatism in 3 children which resolved after treatment. Forty-six percent of children showed color change as an initial response to treatment. Most children (33.3%) responded completely within 5 months after starting the treatment. One third patients (33.3%) showed 100% resolution, 50% showed 90% to 70% resolution. Pretreatment and post-treatment lesion size was1.60 ± 0.86 cm2 and 0.30 ± 0.40 cm2 respectively (p - value &lt; 0.0005). None showed any significant adverse effect of oral propranolol. Conclusion: Low-dose oral propranolol is an effective and cost-effective treatment modality for periocular capillary hemangioma and is safe as an outpatient basis.

Periocular capillary hemangioma in 2018: natural course, indications for treatment and therapeutic options

Periocular capillary hemangioma in 2018: natural course, indications for treatment and therapeutic options

Effect of oral propranolol on periocular Capillary Hemangiomas of Infancy

To assess the safety and efficacy of oral propranolol in the management of periocular Capillary Hemangiomas of Infancy (CHI). Medical records of 21 infants diagnosed with periocular capillary hemangioma during a period of 5 years from 2009 to 2014 were retrospectively reviewed. The data collected included demographic details, clinical features and details of imaging studies and response to the therapy. All patients received oral propranolol under the supervision of a pediatrician. The initial dose was 0.2-1mg/kg body weight, which was increased to 2mg/kg body weight (3 divided doses) in 48h if there was no adverse reaction to the initial dose. The response to the treatment was assessed clinically as well as by radiographic imaging. Photographic documentation was done periodically. Out of 21 patients, 18 were females and remaining three were males. The median age at the time of presentation was 4 months. The most common presenting feature was lid mass (n=17, 80%) followed by proptosis (n=7, 33%). Reddish discoloration of face was seen in 2 (1%) patients. All patients showed reduction in the size of the lesion. None of the patients included in this study had any adverse reaction to propranolol or recurrence following cessation of the therapy. Oral propranolol is highly effective and safe in the treatment of periocular capillary hemangiomas in infants.

β-Blocker versus triamacinolone acetate in the treatment of infantile periocular hemangioma

Purpose The aim of this study was to evaluate the effectiveness of systemic and intralesional β-blockers in the treatment of periocular infantile capillary hemangiomas and to compare the effect of intralesional triamcinolone acetonoid injection and β-blockers. Patients and methods Totally, 60 patients with infantile periocular hemangioma were included in the study and were divided into three groups. Group 1 included 20 patients treated with systemic β-blocker. Group 2 included another 20 patients treated with intralesional triamcinolone acetate. Group 3 included 20 patients treated with intralesional β-blocker. Results In group 1, 55% of patients showed excellent response, 30% of patients showed good response, 10% of patients showed fair response, and 5% of patients showed poor response. In group 2, 50% of patients showed excellent response, 35% of patients showed good response, 15% of patients showed fair response, and no patients showed poor response. In group 3, 40% of patients showed excellent response, 25% of patients showed good response, 25% of patients showed fair response, and 10% of patients showed poor response. Conclusion Systemic propranolol is a good alternative for treating periorbital infantile hemangiomas. Systemic propranolol is superior to intralesional steroid because systemic propranolol has fewer side effects. Propranolol provides a more safe and effective modality of treatment of periocular infantile capillary hemangioma with a lower incidence of systemic side effects.

Infantile Periocular Capillary Hemangioma An Unusual Presentation

A 22 days old infant presented with a large capillary hemangioma involving the right lower eyelid causing a total occlusion of the visual axis. The treatment given was a single intralesional triamcinolone acetonide injection (0.4 mg), followed a month later with systemic steroids (4mg) for 6 weeks. After 6 weeks, there was a significant reduction in the size of the mass resulting in clearing of the visual axis. We herein report a large infantile periocular capillary hemangioma which was successfully managed with a single injection of intralesional and systemic corticosteroids together.

β-blockers in the treatment of periocular infantile capillary haemangioma.

Infantile capillary haemangioma (IH) is the most common congenital vascular tumor of childhood and infancy. Although the majority of these lesions regress spontaneously, many of children with IH particularly in the periocular or orbital region need treatment. Ocular indications for treatment include obstruction of the visual axis or high degrees of astigmatism causing amblyopia, exposure keratopathy secondary to proptosis or compressive optic neuropathy. Our purpose was to assess the effectiveness and tolerance of beta-blockers (BB),propranololand metoprolol, in the treatment of these lesions. We performed aretrospectivereview of 21 infant patients with periocular or/and orbital IH. The mode of treatment for 13 patients was with the non-selective βblocker propranolol (PR) and 8 patients were treated with the β1 selective blocker metoprolol (ME). We analysed the changes in IH lesion size, colour and thickness after the treatment with β-blockers, the onset and the period of their action, recurrence of IH and adverse effects of the treatment. The effectiveness of metoprolol to propranolol was compared as well as their use in combination with systemic steroids. In the first month of the treatment with beta-blockers, significant regression of the IH was observed in all patients. During the following months of treatment the regression was not rapid and after 6 to 12 months the lesions remained stationary. The final result of the treatment of 15 patients (71.4%) was deemed excellent while the treatment of 5 patients (23.8%) was deemed good. Asingle patient (4.7%) had only fair response to the therapy. During the whole series no serious life-threatening adverse effects were observed. The usage of beta-blockers, both propranolol and metoprolol, in the therapy of orbital and periocular capillary infantile haemangioma seems to be very effective in reduction of the tumor and had only rare, minimum adverse effects. These facts favour beta-blockers as the first line treatment of children with IH.

Effects of Dosing Protocol on Distribution of Propranolol in Periocular Tissues after Topical Ocular Instillation

ABSTRACTPurpose: Our previous study demonstrated that topical ocular instillation can deliver effective concentrations of propranolol in the periocular tissues, and may be superior to oral propranolol in the treatment of periocular capillary hemangiomas. The objective of this study was to investigate the effects of dosing protocol on the distribution of propranolol in the periocular tissues and plasma after topical ocular instillation.Methods: Each rabbit received propranolol 0.5% ophthalmic solution using one of the following dosing protocols: three drops of 50 μL, one drop of 50 μL, or one drop of 25 μL. The periocular tissues (e.g. eyelids and extraocular muscles) and blood were collected and assayed for propranolol at 1 h after dosing.Results: Decreasing the concentration of eye drops (1% to 0.5%), decreasing the number of eye drops during dosing (three drops to one drop), or decreasing the instilled volume (50 µL to 25 µL) generally lowered the concentration of propranolol in the periocular tissues. Nevertheless, therapeutic levels of propranolol (> 0.4 μg/g) were delivered to the periocular tissues at 1 h after dosing using any of the three protocols examined. Dose-dependent concentrations in some periocular tissues and plasma were observed over the dose range of 0.125 mg to 1.5 mg. The plasma concentration of propranolol was not measurable when a single 25 μL of propranolol 0.5% was instilled in the eye.Conclusions: The dosing protocol of topical ocular instillation can be tailored to achieve the desired therapeutic concentrations of propranolol in the periocular tissues while minimizing systemic exposure.

Visual acuity and astigmatism in periocular capillary hemangiomas treated with oral beta-blocker versus intralesional corticosteroid injection

Periocular infantile capillary hemangiomas (PCH) can induce anisometropic astigmatism, a risk factor for amblyopia. Oral beta-blocker therapy has largely supplanted systemic or intralesional steroid for vision-threatening lesions.

Propranolol and periocular capillary hemangiomas: assessment of refractive effect.

To assess the effects of systemic propranolol on refractive error in infants with periocular capillary hemangiomas. A single-center study of consecutive patients with capillary hemangiomas treated with systemic propranolol. Refractive data were analyzed using Long's matrix formalism and the methods of Harris and Kaye. Seventeen patients were included. At 6 months postoperatively, hemangioma size reduced from 3,214 to 1,806 mm(3) (standard deviation: 4,122 to 2,441). Mean refractive error in the affected eye significantly reduced: -1.25/0.38 × 36 (95% confidence intervals: -5.08/1.20 × 90 to 1.64/1.43 × 180, P = .048) with a smaller change (P = .06) in the unaffected eye of -1.01/+0.31 × 3.16 (95% confidence intervals: -4.02/+1.12 × 180 to +1.49/+0.51 × 90). Propranolol produced a clinically significant reduction in the infants' refractive error and anisometropia. The reduction in the total refractive error and anisometropia has not been evident in previous analyses, which have concentrated on the change in the "cylinder" as the principal outcome measure.

Alternative treatment modality for periocular infantile hemangioma

Background: Capillary hemangiomas are the most common tumors of the eyelids and orbit in children. They typically appear at or shortly after birth, with approximately 90% being clinically obvious by 2 months of age. Complications include functional sequelae like anisometropia, amblyopia, visual axis impairment; cosmetic sequelae like scarring, ulceration, bleeding, displacement of the globe, proptosis and even optic nerve compression. Therapeutic options include corticosteroids, beta-blockers, pulse dye laser, topical imiquimod, interferon-α, vincristine, cyclophosphamide and surgery. Aim: The aim of our study is to investigate the efficacy of intralesional triamcinolone and combination of intralesional triamcinolone with topical timolol in treatment of periocular infantile hemangioma & its recurrence. Method: This prospective study was performed in 24 patients with periocular hemangiomas requiring intervention. Patients were arranged in two groups: Triamcinolone acetonide intralesional injection alone & combination of triamcinolone acetonide intralesional injection with timolol maleate local application. Patients were followed up for three months. The size of the hemangioma was measured in mm2. Result: In Group 1, 66.66% of patients showed good response while in group 2, 88.89% of patients showed good response. Group 2 showed less recurrence rate than group 1. None of the patients developed local side effects during or after injection. Conclusion: Beta blocker and intralesional steroid both are relatively safe and effective for the periocular capillary hemangioma. Beta blocker with intralesional steroid has less chances of recurrence than beta blocker and steroid alone. Keywords: Infantile hemangioma, Triamcinolone acetonide, Timolol maleate.

Periocular capillary hemangioma: management practices in recent years

PurposeTo present a case series on the management options for capillary hemangiomas involving the eyelid and orbit.MethodsThis 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.ResultsSixteen 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).ConclusionClose 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.

Intralesional bleomycin injection for periocular capillary hemangiomas

Dear Editor, We read the article by Smit and Meyer[1] with keen interest. We wish to express the following comments: Intralesional bleomycin injection (IBI) is a newer form of therapy for capillary hemangioma with encouraging results.[1,2,3,4,5] IBI was used for the first time for complicated cutaneous hemangiomas.[2] Experience with IBI for periocular capillary hemangiomas is very limited. Authors diagnosed capillary hemangioma by clinical examination only.[1] We believe clinical evaluation should have been combined with ultrasonography or magnetic resonance imaging or color doppler to differentiate hemangioma from vascular malformation.[3,4,5] Color doppler is also of immense utility during follow-up in detecting size, color, and blood flow changes after IBIs. Blood flow in capillary hemangioma declines after four to five IBIs; blood flow signal disappears earlier than color (usually after five to six IBIs for a lesion diameter less than 4 cm).[3,4] Authors discontinued therapy after administering nine IBIs in case one and after five IBIs in case two.[1] We appreciate the result with respect to opening of eye and increase in vertical height of palpebral fissure which might be adequate to prevent stimulus deprivation amblyopia, however, post IBI Figures 2 and 4 clearly depict significant residual capillary hemangioma covering the forehead, nose, upper lip, and even left upper eyelid of case 1 and forehead, nose and right upper eyelid of case 2 respectively.[1] We believe the treatment should not have been stopped at this stage. The hemangioma involving forehead, nose, and lips still required intralesional bleomycin. It has been suggested that the interval of injection should be 3-4 weeks with total times lesser than 7 times during one therapeutic period.[3,4] Another therapeutic period may be started 3 months later if further treatment was necessary. The total quantity of bleomycin for a child should be less than 40 mg in one treatment periods.[3,4] Luo and Jhao reported very large series of 82 cases of infantile hemangiomas which involuted completely after treatment with the sclerosing mixture composed of 2% lidocaine, 5 mg dexamethasone and 8 mg bleomycin A5 and also used oral prednisolone (2-5 mg/kg every other day).[3,4] Combination of dexamethasone with bleomycin as well as oral prednisolone has been advocated to treat effectively the patients at proliferating stage observed in the 3rd and 6th month in many cases of infantile hemangioma and also to circumvent the dose restriction of bleomycin i.e., the drug quantity given in one time may be deficient for big hemangioma(>4 cm).[3,4] Authors suggest use of bleomycin in the treatment of eyelid hemangiomas where conventional modalities have been unsuccessful or where treatment with beta-blockers may be contraindicated.[1] Many investigators recommend oral propranolol as the first line of therapy for infantile hemangioma.[6] Readers would be interested to know why authors[1] did not treat these cases with oral propranolol as first line therapy.

Oral Propranolol in the Management of Periocular Capillary Hemangiomas

Oral Propranolol in the Management of Periocular Capillary Hemangiomas

Reply to Spiteri Cornish and Reddy

Sir, We read with interest the paper by Spiteri Cornish and Reddy entitled ‘The use of propranolol in the management of periocular capillary haemangioma – a systematic review.'1 The authors provide an excellent review regarding the changing paradigms for the management of patients with infantile haemangiomas (IHs) and provide clear evidence as to the effectiveness of propanolol. The authors were unable to find an RCT comparing propanolol with a recognised standard or a placebo and concluded that an RCT would be beneficial but difficult to perform. The primary reason being that clinical equipoise cannot be met; given the weight of recent evidence the majority of clinicians would now be reluctant to revert to previous treatments for IHs, and therefore cannot ethically choose at random which treatment to provide.2 An RCT in this situation will have inherent flaws with confounding factors and bias. Glasziou et al3 ask whether an RCT in this situation is actually required, illustrating similar historic milestones in medical practice where a new intervention has provided equally dramatic results. Occasionally, an RCT is not performed despite the intervention becoming mainstream practice, with examples including insulin to treat diabetes, defribrillation for ventricular fibrillation, and sutures to repair large wounds. They go on to describe the ‘rate ratio' between the signal or intervention (propanolol) and the background noise (previous treatments). This is calculated as the rate of improvement of the lesion during the new treatment divided by the rate with previous treatments. Ideally, this ratio should be over 20, that is treatment with propanolol should increase the rate of improvement by over a factor of 20 when compared with a control that allows for bias and other confounding factors. Clearly, the efficacy of propanolol is not disputed and issues regarding adverse effects should now be monitored using long-term data collection in the form of either a prospective database or registry. Such observational data will highlight rarer treatment complications and long-term effects. The optimal mode, dose, and duration of treatment of propanolol are yet to be defined and well-designed RCTs in this context would certainly be of benefit.

Propranolol treatment for periocular capillary haemangiomas – experience from a tertiary referral hospital

Aims To describe our experience in treating periocular capillary haemangiomas with propranolol. Methods Descriptive case series. We describe the protocol used and our results including photographs pre-treatment and showing the treatment response. We also discuss the side effects and complications we have encountered. Results We have a cohort of 8 patients (2 orbital, 5 periocular, and 1 brow haemangioma). We use a starting dose of 1 mg/kg/day in 3 divided doses increasing to 2 mg/kg/day after 1 week if tolerated. Six of our patients have responded very well to the treatment and have had no side effects to date. One patient has only recently commenced treatment. The propranolol was stopped in one case due to loss of appetite which coincided with the commencement of propranolol but has recently been restarted. We have had one drug error where the dispensing community pharmacist gave the 50 mg/5 ml propranolol concentration with labelled dose for 5 mg/5 ml concentration resulting in the infant receiving ten times the prescribed dose. He was admitted for monitoring with no ill effect. Photo of one of our patients pre and post treatment – figure 1 and 2. Conclusion Propranolol is an effective treatment for periocular capillary haemangiomas. In our cases it has provided good functional and cosmetic outcomes and been well tolerated with no serious adverse effects to date.

A Case of Periocular Capillary Hemangiomas Treated With Propranolol as a Single Therapy

A Case of Periocular Capillary Hemangiomas Treated With Propranolol as a Single Therapy