Treatment of Infantile Capillary Hemangioma of the Eyelid with Systemic Propranolol

Journal Reading

Supervisor:dr. Angela Shinta, Sp.M

Presented by:Francisca Bunjamin (2010.061.054)

Fabiola Vania Felicia (2010.061.133)Margaretha Syane L. (2011.061.006)

Lettisia Amanda R. (2011.061.157)

INFANTILE CAPILLARY HEMANGIOMAS (1)•Most common tumors of eyelid in infancy•Appear shortly after birth

involute spontaneously in early childhood many lesions do not need to be treated

•Complications:▫Vision loss secondary to amblyopia induced by

astigmatism▫Ptosis▫Globe displacement

INFANTILE CAPILLARY HEMANGIOMAS (2)•Therapeutic options:

▫First line Intralesional, topical, or systemic

corticosteroids▫Secondary options

Interferon α, vincristine, cyclophosphamide, topical imiquimod, focal laser photocoagulation, surgical excision

•In 2008 succesful effect of oral propanolol therapy was reported

METHODS

•All patients with eyelid infantile capillary hemangiomas at risk of occlusive or refractive amblyopia

•Recruitment:▫at Pediatric Ophthalmology Dept &

Pediatric Dept of University Federico II, Italy

▫January 2009 – January 2012

PROSPECTIVE INTERVENTIONAL STUDY

Main inclusion criterion

•Eyelid hemangioma that could determine occlusive or refractive amblyopia because of its position and size

Exclusion criteria for treatment

•Intraconic lesion•Congestive cardiac failure•Asthma•Obstructive pulmonary disease

TREATMENT:Propranolol

2 mg/kg body weight/day- Maximum period of 4

months

2 visits within1 month

-Cardiology evaluation

FOLLOW UP:-Minimum period of 6 months-Ophthalmologic examinations

OUTCOME MEASUREMEN

T

STOP TREATMENT:-Complete flattening of hemangioma-Adverse effect

Before Treatment

•2 visits within 1 month▫Exclude spontaneous improvement of

lesion•Cardiology evaluation

▫Electrocardiography & echocardiography▫Monitoring the unwanted general effects of

β-blockers

Follow-up (1)

• Side effects of therapy• Ophthalmologic examinations:

▫ Visual fixation preference▫ Eyelid function & ptosis▫ Extraocular motility▫ Anterior segment▫ Dilated funduscopy▫ Cycloplegic refraction

baseline 1 week 1 month monthly intervals

-total regression-after therapy ended

Minimum period of 6 months

Follow-up (2)

•Significant amblyogenic factors: Difference of ≥1.50 in astigmatism, ptosis, eyelid contour changes, strabismus, or globe displacement

•Size of hemangioma▫B-scan echography, clinical examination,

photography

Follow-up (3)

•Visual Analog Scale▫To compare the response to treatment▫Clinical score:

100-mm VAS (-100 to +100) -100 : doubling in size 0 : absence of change +100 : complete resolution

▫Percentage of change from baseline 5 mm ≈ 5 %

Outcome

•Main outcome measure:▫Post treatment regression of lesions

(by VAS & echography)•Secondary outcome measures:

▫Improvement in astigmatism, amblyopia, visual acuity, the safety of therapy

RESULTS

Results (1)•17 patients eyelid hemangioma --> 3

excluded (history of asthma) --> 14 patients treatment with systemic propanolol

•Age : 20,85 ± 29,7 months (2-96 months)

•No born prematurely and none had ongoing cardiac or obstructive pulmonary disease

Results (2)•Concurrent extraocular localization of

hemangiomas was present in 3 cases (abdomen, neck, thigh)

• No case was a previous steroid or alternative treatment administered

•Treatment was discontinued in 1 case (7 months) because of arterial hypotension (improved 1 hour after discontinuation of treatment), and 1 case (4 years) because of a skin rash

Results (3)•Mean treatment duration 2,5±1,3 months

(1-4 months)

•In all cases, rapid reduction in the size, flattening and lighter coloration at 1 week visit was observed

•No recurrence after propanolol discontinuation

• 7 males & 7 females• 10 on the upper eyelid + 4 on the lower eyelid• The mean follow-up duration was 10,64±8,7

months (6-39 months)

Patient Characteristics (1)

Patient Characteristics (2)

• Mean astigmatism value in affected eye from 1,25 ± 0,5 D before treatment 0,25 ± 0,2 D at last visit

• Amblyopia improved in all cases

Patient Characteristics (3)

Lesion Characteristics (1)

Lesion Characteristics (2)

DISCUSSION

Disscussion (1)

•A dramatic effectiveness, low incidence of side effects, and no recurrences after termination of therapy were observed

• Recurrence rate after propranolol seems inversely correlated with age high proliferative rate of the lesion in younger patients

•In our series, no patient was younger than 2 months, and this could explain the absence of recurrences

Disscussion (2)

•Complete regression of lesion 9 of 14 patients (all < 1 year) (64.3%)

•5 patients no complete regression 4 were older than 1 year

•Age at treatment onset influence final outcome lesions in the proliferative phase are more susceptible to propranolol

Disscussion (3)• 2 patients > 5 years significant although

incomplete regression of the mass• Previous studies report a mean age at

treatment onset of less than 1 year because of the supposed greater effect of propranolol on proliferative capillaries

• After 8 months th/ with oral propranolol (2mg/kg daily), the mass reduced significantly and regrowth was not observed propranolol may be a valid therapeutic option even after 5 years of age

Disscussion (4)• Propranolol treatment was administered maximum

4 months• In 9 (90%) of 10 patients < 1 year at treatment

onset significant regression• In patients > 1 year (23, 48, 72, and 96 months of

age) regression but incomplete• Results:

- 4 months treatment sufficient for complete regression in patients < 1 year

- Older patients, a longer duration of treatment not correlated with proportionally greater regression of lesions

Disscussion (5)

•Astigmatism was present in 4 cases and to a nonamblyogenic level after treatment

• Treatment of sight-threatening periocular infantile capillary hemangiomas should be started early and before amblyopia develops

Disscussion (6)

•Propranolol effects include bronchospasm, hypoglycemia, mood disturbances, somnolence, bradycardia, and hypotension

•In the present study, we observed arterial hypotension in one case and a skin rash (allergic reaction)

Conclusion

•Oral propranolol was effective in the treatment of eyelid infantile capillary hemangiomas

•Complication rate was low •Greater effect was present in infants,

patients older than 5 years also benefited from propranolol treatment

•Treatment duration of 4 months seems sufficient to obtain the maximum effectiveness

Thank You