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
Secondary options
Interferon , vincristine, cyclophosphamide, topical imiquimod, focal laser photocoagulation, surgical excision
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
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
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
Outcome
Main outcome measure:
Post treatment regression of lesions (by VAS & echography)
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
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)
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
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