Ophthalmology

Beta-blockers and immune modulators are effective in treating several forms of periocular lesions, according to a physician at OSN New York 2011.

Capillary hemangiomas

Non-selective beta-blockers offer an important alternative to the traditional steroidal and surgical treatment of capillary hemangiomas, Jill Melicher, MD, said.

“The established treatment of capillary hemangiomas involves steroids as well as surgical incision. Interlesional steroids with a combination of triamcinolone and betamethasone is a good, useful treatment. Its most severe side effect, however, is embolization,” she said.

Capillary hemangiomas, hamartomas, are the most common benign tumors in children, she said. Young patients can develop abnormalities to the overlying skin as the lesions grow, requiring difficult reconstructive procedures down the road. Oral steroids are a good treatment option but come with a significant systemic side effect profile, including cushingoid appearance, difficulty sleeping and steroid dependence, Dr. Melicher said.

The beta-blocker propranolol offers a valid, although off-label, alternative treatment, Dr. Melicher said. It was discovered to be an effective treatment for infantile hemangioma when decreased redness and softening of these lesions were observed in patients being treated with the drug for cardiac disease.

The mechanism of action for non-selective beta-blockers involves vasoconstriction, decreased expression of VEGF and pro-angiogenic growth factors, and the triggering of hypoxia-induced apoptosis of capillary endothelial cells. Systemic side effects include bronchospasm, heart block, hypotension, bradycardia and hypoglycemia, according to Dr. Melicher.

“So then it was thought: Well, if we can use systemic beta-blockers, why can’t we use topical beta-blockers to achieve a similar effect?” Dr. Melicher said.

The topical beta-blocker timolol maleate has been an effective treatment with few drawbacks and no reported systemic side effects, Dr. Melicher said. The mechanism of action is thought to be similar to that of propranolol, she said.

“In my patients [with] non-amblyogenic capillary hemangioma lesions on the eyelid, I have tried timolol rubbed into the lesion twice per day with good effect to promote the involutional phase of the lesion,” she said.

Basal cell carcinomas

There are new advancements from the dermatology literature for nonsurgical treatment of biopsy-proven superficial basal cell and premalignant actinic keratosis with topical medications. Traditionally these lesions have been treated with primary excision using frozen section control or Mohs micrographic surgery, Dr. Melicher said.

Dermatologists have been using topical 5% imiquimod cream to treat superficial basal cells such as premalignant actinic keratoses, she said. This medication has been used around the eye for treatment of biopsy-proven superficial basal cell and actinic keratosis with good effect.

“Topical 5% imiquimod is an immune modulator. It induces pro-inflammatory cytokines followed by cytotoxic T-cell-mediated death,” Dr. Melicher said.

The cream is dosed once daily, 5 days per week for 6 weeks, she said.

“It’s [U.S. Food and Drug Administration] approved for use everywhere but the face,” she said, “but recent articles have suggested that it can be useful in facial lesions, as well as periocular lesions.”

This treatment is indicated only in cases of biopsy-proven lesions, she said.

When used in the periocular region, side effects such as foreign body sensation, injection and lid hyperemia have been observed, but the use of cellulose in the eye largely dissipated these effects, she said.

“Topical 5% imiquimod is a useful first-line agent, specifically for actinic keratoses, but also in patients [with] biopsy-proven superficial basal cell carcinomas who don’t qualify for surgery or [in patients who have] refused surgical removal,” she said. – by Daniel R. Morgan

Reference:

• Bakri SJ, Snyder MR, Reid JM, Pulido JS, Singh RJ. Pharmacokinetics of intravitreal bevacizumab (Avastin). Ophthalmology. 2007;114(5):855-859.

For more information:

• Jill Melicher, MD, can be reached at Minnesota Eye Consultants, 9801 Dupont Ave. S, Suite 200, Bloomington, MN 55431; 952-888-5800; email: jsmelicher@mneye.com.
• Disclosure: Dr. Melicher has no relevant financial disclosures.