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Figure 1.
Before topical treatment, a large capillary hemangioma involved the child's left upper eyelid, inducing mechanical blepharoptosis and covering her left pupil.

Before topical treatment, a large capillary hemangioma involved the child's left upper eyelid, inducing mechanical blepharoptosis and covering her left pupil.

Figure 2.
After a few weeks of treatment with topical β-blocker eyedrops, the hemangioma was significantly reduced in size, thickness, and color. The mechanical blepharoptosis also improved significantly, clearing the visual axis.

After a few weeks of treatment with topical β-blocker eyedrops, the hemangioma was significantly reduced in size, thickness, and color. The mechanical blepharoptosis also improved significantly, clearing the visual axis.

1.
Slaughter  KSullivan  TBoulton  JO’Reagan  PGole  G Early surgical intervention as definitive treatment for ocular adnexal capillary haemangioma. Clin Experiment Ophthalmol 2003;31 (5) 418- 423
PubMedArticle
2.
Schwartz  SRBlei  FCeisler  ESteele  MFurlan  LKodsi  S Risk factors for amblyopia in children with capillary hemangiomas of the eyelids and orbit. J AAPOS 2006;10 (3) 262- 268
PubMedArticle
3.
Peralta  RJGlavas  IP Review of capillary hemangioma. EyeNet February2009;35- 37
4.
Léauté-Labrèze  CDumas de la Roque  EHubiche  TBoralevi  FThambo  JBTaïeb  A Propranolol for severe hemangiomas of infancy. N Engl J Med 2008;358 (24) 2649- 2651
PubMedArticle
5.
Weiss  AHKelly  JP Reappraisal of astigmatism induced by periocular capillary hemangioma and treatment with intralesional corticosteroid injection. Ophthalmology 2008;115 (2) 390- 397, e1
PubMedArticle
6.
Siegfried  ECKeenan  WJAl-Jureidini  S More on propranolol for hemangiomas of infancy. N Engl J Med 2008;359 (26) 2846- 2847
PubMedArticle
Research Letters
February 2010

Topical Treatment for Capillary Hemangioma of the Eyelid Using β-Blocker Solution

Author Affiliations

Author Affiliations: The Institute of Ophthalmology and Visual Science, University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark (Dr Guo); and Yale University School of Medicine, New Haven, Connecticut (Ms Ni).

Arch Ophthalmol. 2010;128(2):255-256. doi:10.1001/archophthalmol.2009.370

The prevalence of periorbital or eyelid hemangioma ranges from 1% to 3%. There are more than 1.5 million affected children in the United States.1 Amblyopia is the most common complication of capillary hemangioma of the eyelid in children, with an incidence of 60%. If it is not treated promptly, it may lead to irreversible blindness in young children.2 The treatment options include corticosteroids, interferon alfa-2a, laser therapy, embolization, immunomodulators, surgery, and systemic propranolol.1,3,4 All therapeutic options are associated with adverse effects, some of which are serious. The treatment of a large capillary hemangioma on a child's left upper eyelid using topical β-blocker solution is reported. The hemangioma significantly improved within a few weeks of the topical treatment.

Report of a Case

A 4-month-old girl had a large capillary hemangioma on her left upper eyelid that induced blepharoptosis and covered her pupil (Figure 1). Her right eye followed and fixated well, while the left eye was slow to fixate. She was orthophoric with full duction and version in all fields of gaze. Her ocular examination showed a normal anterior segment, optic nerve, and retina in both eyes. Her cycloplegic retinoscopy results were +3.50 − 1.50 × 180° OD and +4.50 − 3.75 × 180° OS with more than 2 diopters of induced astigmatic anisometropia. The child's mother was instructed to apply timolol maleate, 0.5%, ophthalmic solution twice daily, 2 drops onto the surface of the hemangioma with a gentle spread using a finger. The child was not receiving systemic medication and was followed up by her pediatrician during the treatment period. After 5 weeks of treatment, the hemangioma was significantly reduced in size, thickness, and color, clearing the visual axis (Figure 2). Topical β-blocker treatment was discontinued at 7 weeks and repeat retinoscopy results at 11 weeks improved to +4.00 − 1.50 × 180° OS. The child has been followed up for 4 months and tolerated the topical treatment well. No local or systemic adverse effects were noted.

Comment

Capillary hemangioma is the most common benign tumor of the eyelid or orbit in children. It affects more than 2% of infants.3 Indications for treatment are amblyopia, compressive optic neuropathy, and exposure keratopathy.1,3 All current therapeutic options can be associated with systemic adverse effects. First-line therapy includes oral or intralesional corticosteroids. The complications of corticosteroid treatment include disfiguring eyelid changes, elevated intraocular pressure, central retinal artery occlusion, hypertension, and adrenal cortical insufficiency.1,3,5 Surgical excision can be complicated by hemorrhage and infection. Therapy with immunomodulators has been associated with myelosuppression and hepatotoxic effects (cyclophosphamide) and neurotoxic effects (interferon alfa-2a).3

Most recently, systemic application of propranolol was reported to successfully treat severe hemangioma in infants.4 However, oral application of propranolol can cause severe systemic complications. These include bronchospasm, vasospasm, hypoglycemia, hypotension, severe bradycardia, heart blockage, and congestive heart failure.6 Our case demonstrates that the application of topical β-blocker solution produced significant reduction of a large capillary hemangioma and resulted in the clearance of the child's visual axis within a few weeks of treatment. No local or systemic adverse effects were noted.

These results suggest that topical β-blocker administration provides a safe and effective alternative to systemic use in the treatment of capillary hemangioma. Our ongoing studies include a case series on the treatment of capillary hemangioma with topical β-blocker solution and a comparison of the efficacy and adverse effects of topical vs systemic β-blocker in the treatment of capillary hemangioma of the eyelid.

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Article Information

Correspondence: Dr Guo, The Institute of Ophthalmology and Visual Science, University of Medicine and Dentistry of New Jersey–New Jersey Medical School, 90 Bergen St, DOC 6100, Newark, NJ 07101 (guos1@umdnj.edu).

Financial Disclosure: None reported.

References
1.
Slaughter  KSullivan  TBoulton  JO’Reagan  PGole  G Early surgical intervention as definitive treatment for ocular adnexal capillary haemangioma. Clin Experiment Ophthalmol 2003;31 (5) 418- 423
PubMedArticle
2.
Schwartz  SRBlei  FCeisler  ESteele  MFurlan  LKodsi  S Risk factors for amblyopia in children with capillary hemangiomas of the eyelids and orbit. J AAPOS 2006;10 (3) 262- 268
PubMedArticle
3.
Peralta  RJGlavas  IP Review of capillary hemangioma. EyeNet February2009;35- 37
4.
Léauté-Labrèze  CDumas de la Roque  EHubiche  TBoralevi  FThambo  JBTaïeb  A Propranolol for severe hemangiomas of infancy. N Engl J Med 2008;358 (24) 2649- 2651
PubMedArticle
5.
Weiss  AHKelly  JP Reappraisal of astigmatism induced by periocular capillary hemangioma and treatment with intralesional corticosteroid injection. Ophthalmology 2008;115 (2) 390- 397, e1
PubMedArticle
6.
Siegfried  ECKeenan  WJAl-Jureidini  S More on propranolol for hemangiomas of infancy. N Engl J Med 2008;359 (26) 2846- 2847
PubMedArticle
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