Mungan: We are going to discuss the management of periocular infantile hemangioma. A 6-week-old female infant is referred by her pediatrician for a 7-mm somewhat raised capillary hemangioma on the upper eyelid that has been growing rapidly. There is 1 to 2 mm of ptosis, but no amblyopia, anisometropia, or strabismus. What is your typical approach to such a patient?
Rychwalski: In this patient, because of the relatively young age, it is important to not act aggressively at first. I would certainly measure the lesion, take photographs, and ask the parents if they have photographs of when the child was even younger to get a better idea of the progression to see if it's rapidly proliferative. Other than doing a general eye examination and a refraction to make sure there's no astigmatism, I might offer the patient treatment with a topical beta-blocker. I would have the patient come back in 2 or 3 weeks for a follow-up to get more data points and follow the progression of the lesion.
Howard: I would be reluctant to be aggressive at this point because the child is so young. If there is no sign of amblyopia or anisometropia, I would follow the patient closely. I also agree with documenting the current findings, including photographic history and current status, and doing a complete examination with a cycloplegic refraction as baseline eye findings. I would see the patient again in approximately 3 weeks. But I would hold off on any treatment at this point.
Olitsky: If the parents had photographs or described a dramatic recent change in the appearance over the past few weeks, I might be more aggressive. Depending on the examination and other findings, I would probably talk about treating this patient. Given her age, if it's been rapidly advancing, it's safe to say that it is going to continue to do so. Ten years ago, I probably would have watched a little longer or managed this either optically or with patching if there was some sign of amblyopia. But now I would probably send this patient for treatment if I had any indication that this had changed in the past few weeks.
Mungan: Do you initiate treatment yourself in the pediatric ophthalmology office, or do you refer to another specialist?
Olitsky: The dermatologists typically treat these patients in my area.
Howard: I work with a pediatric dermatologist who would initiate the treatment.
Rychwalski: We do not currently have a pediatric dermatologist on staff. There are some in the community, but they are so backed up that it is difficult to get the patients in to see them. I work primarily with a pediatric cardiologist to determine dosing and then will monitor the patient for the first visit.
Mungan: Does the initiating physician start the patient on treatment as an outpatient or an inpatient?
Rychwalski: They have a protocol for a brief inpatient monitoring for some children, but typically it's just an outpatient appointment. If they use oral propranolol, they'll lower the initial doses slightly if they're monitoring as an outpatient.
Howard: The dermatologist I work with will start patients as outpatients. If they are younger than 5 weeks of age or have ptosis that is blocking the eye or extreme astigmatism, then they will start them as an inpatient. Otherwise, they are monitored in three out-patient visits as the propranolol is administered with a small dose and then increased to make sure that they're doing well with it.
Mungan: Do any of you find that your initiating physician prefers brand name propranolol that's been specifically manufactured for use in hemangiomas versus the generic propranolol that was originally intended for cardiovascular indications?
Olitsky: I'm not aware that they are.
Howard: Not to my knowledge.
Rychwalski: I have not been aware of strict brand preference.
Mungan: If a good response occurs, how soon do you consider advising weaning the patient, albeit in consultation with the initiating physician?
Rychwalski: My understanding is that the proliferative phase is typically within the first year of life. I generally like to see stability for 6 months before I recommend any type of taper.
Olitsky: I would agree with that. I like to see them get through that age where you typically see progression and demonstrate stability for several months afterwards.
Howard: The dermatologist sees the patient immediately after my examination so we are in sync with the treatment and agree on the direction in which the patient's eye examination is going. In my experience, the window of progression can be longer than a year.
Mungan: Do you mean longer compared to when we were using steroids?
Howard: For some of these patients, it's just taking longer than a year for the hemangioma to involute and become smaller.
Mungan: If that same patient has contraindications to receiving beta-blockers and continues to worsen and progress rapidly, what is your next line of treatment?
Rychwalski: I would typically go next to an oral corticosteroid. Due to the possibility of side effects, I would work closely with the pediatrician on dosing. The starting dose is typically 1 to 2 mg/kg.
Olitsky: I agree with that dose. I think the dermatologist will go as high as 3 to 4 mg/kg, depending on how fast they want to see the response or certainly if the child hasn't responded to a lower dose.
Howard: I agree with pursuing oral steroids as a secondary treatment.
Mungan: Is there still a role for intralesional steroids?
Olitsky: I have probably not injected a patient in more than 15 years. I think oral steroids are effective. The dermatologists are well aware of the side effects and watch for them and feel they are manageable.
Rychwalski: That's my experience as well. The drawbacks to intralesional steroids include atrophy and necrosis over the skin. There have also been reports of central retinal artery occlusion, which makes that type of treatment less appealing.
Howard: I would not inject with an intralesional steroid. I would offer surgery if the lesion appeared amenable to that, but if the family did not opt for surgical treatment, then I would offer systemic steroids if propranolol was not effective.
Mungan: In the case of a 3-month-old infant with a treated hemangioma and 2.50 diopters of anisometropic astigmatism, at what point would you prescribe glasses?
Howard: I would initially start with propranolol and check on the effectiveness of the treatment by closely monitoring for amblyopia and any change in the cycloplegic refraction. If amblyopia develops, I like to patch as a first step, because frequently the astigmatism will resolve or greatly diminish in time from the propranolol. Glasses are often not needed, but if this level of astigmatism persists beyond age 15 to 18 months, then I would prescribe glasses.
Rychwalski: I think that's definitely a sound approach. An alternative would be to see if your treatment is working and there's rapid resolution. Perhaps having one more data point and then bringing the patient back for refraction a few weeks later might help avoid needing glasses; 2.50 diopters is fairly high and potentially amblyogenic. If you have a good relationship with the parents and there are signs of involution, that would be another approach.
Olitsky: I would observe those patients. I think it's difficult for the families to get these children to wear glasses. I generally patch those patients for short periods each day. My rationale is if that patient did not have a hemangioma and had that anisometropia, we may not catch that patient until the pre-kindergarten screening. I think the patient has a good chance of doing well with occlusion therapy, so I probably would wait until it was easier to fit that child with glasses, which may be closer to 9 or 12 months of age.
Mungan: How do you counsel parents who ask you to treat a lesion for purely cosmetic reasons?
Olitsky: As long as the parents understand the risks, albeit small, of treatment, I think it's reasonable to discuss with them and refer to a dermatologist. My experience has been that they already saw the dermatologist and they're getting treatment for cosmesis.
Howard: I agree. There are also options to treat, such as topical timolol. If it is a superficial hemangioma, pulsed dye laser treatments can be offered by the dermatologist. Because the hemangioma is prominent on the face, I understand their desire to improve the appearance.
Rychwalski: I agree with my colleagues. It is well worth a discussion of risks and benefits. I believe that using the word cosmetic is not always appropriate. Using terms like reconstructive in some cases may be more helpful.
Mungan: Thank you all for participating.
This Eye to Eye session was conducted on July 15, 2019.