Treatment of Infantile Capillary Hemangioma of the Eyelid with Systemic Propranolol

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)

Journal Reading

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

In 2008 succesful effect of oral propanolol therapy was reported

PROSPECTIVE INTERVENTIONAL STUDY

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

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

2 visits within 1 month -Cardiology evaluation

TREATMENT: Propranolol
2 mg/kg body weight/day - Maximum period of 4 months

FOLLOW UP:
-Minimum period of 6 months -Ophthalmologic examinations
STOP TREATMENT: -Complete flattening of hemangioma -Adverse effect

OUTCOME MEASUREMENT

Before Treatment
2 visits within 1 month
Exclude spontaneous improvement of lesion

Cardiology evaluation
Electrocardiography & echocardiography Monitoring the unwanted general effects of blockers

Follow-up (1)
Minimum period of 6 months baseline 1 week 1 month monthly intervals -total regression -after therapy ended

Side effects of therapy Ophthalmologic examinations:

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

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 (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 2,51,3 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

Patient Characteristics (1)

7 males & 7 females 10 on the upper eyelid + 4 on the lower eyelid The mean follow-up duration was 10,648,7 months (6-39 months)

Patient Characteristics (2)

Patient Characteristics (3)

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

Lesion Characteristics (1)

Lesion Characteristics (2)

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