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A 7-week-old infant with right upper eyelid mass
Digital Journal of Ophthalmology 2010
Volume 16, Number 4
October 2, 2010
DOI: 10.5693/djo.03.2010.09.001
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John Davis | University of Texas Medical Branch at Galveston
Kapil Kapoor | University of Texas Medical Branch at Galveston
Diagnosis and Discussion
The diagnosis in this case was capillary hemangioma as evidenced by the clinical and histological appearance of the lesion. Capillary hemangiomas, previously known as strawberry hemangiomas, are hamartomatous growths of vascular endothelial cells.(1) They are not generally present at birth but appear within the first few weeks of life, reaching their peak size at approximately 6-12 months before decreasing in size over the next 4-5 years. Many of these capillary hemangiomas spontaneously resolve, with studies showing resolution of 50% by 5 years and 80% by 8 years. Ophthalmological indications for treatment include occlusion of visual axis or induced astigmatism, leading to concern for ambylopia.(2)

Numerous treatments exist for capillary hemangiomas. Small non-elevated lesions can frequently be observed. First-line treatment for larger lesions typically includes corticosteroids, which can be administered topically (0.05% clobetasol cream) for superficial lesions, by intralesional injection (40mg/mL triamcinolone and 6mg/mL betamethasone) for intermediate or periorbital lesions, and orally (2mg/kg/day) for refractory lesions.(7) Corticosteroids carry signifcant risk, with systemic corticosteroids potentially causing growth retardation, personality changes, infections, adrenal crisis, diabetes risk, and even rebound growth on cessation.(8) Topical clobetasol cream minimizes many of these risks but still causes dermal atrophy and pigmentary changes, and it can take several weeks to achieve a therapeutic response.(8) Intralesional corticosteroid injection is often used as a first-line treatment, although it adds the risk of central retinal artery occlusion, which has been reported in the contralateral eye as well.(8)

Pulsed-dye laser therapy has been shown to successfully treat flat superficial lesions or residual surface blood vessels after steroid treatment.(9) This therapy has been particularly useful in cosmetically significant areas, including the periocular region. Surgical excision may be employed in refractory cases, particularly with lesions that appear well circumscribed. These lesions are not typically encapsulated, so there is a potential for recurrence as well as a risk of bleeding and a risk associated with general anesthesia.(9)

Interferon alpha-2a, which has been shown to inhibit angiogenesis and endothelial cell migration and proliferation in vitro, has shown promise in refractory cases as well; however, its use has adverse effects, including motor developmental delay and spastic diplegia.(10)

Propranolol has shown great promise in the treatment of capillary hemangiomas.(11,12) In one study, 11 children with capillary hemangiomas were administered 2mg/kg/day of propranolol. Many of these patients began exhibiting color changes of their lesions within 24 hours, and all patients experienced resolution of their capillary hemangiomas, although varying treatment intervals were required.(11) It has been hypothesized that propranolol causes vasoconstriction of this highly vascular lesion and acts to down-regulate vascular endothelial growth factor and basic fibroblastic growth factor (bFGF), eventually triggering apoptosis of capillary endothelial cells.(11)