Benefits and complications of photodynamic therapy of papillary capillary hemangiomas

OBJECTIVE: To evaluate the potential benefit and risks of photodynamic therapy (PDT) in the treatment of papillary capillary hemangioma. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Five patients with solitary capillary hemangioma on the temporal portion of the optic nerve presenting with exudative decompensation and decrease in visual acuity (VA). METHODS: All eyes received a standardized PDT treatment with 6 mg/kg body surface area verteporfin and application of 100 J/cm(2) light at 692 nm. One to three PDT courses were performed until resolution of exudation was achieved. A continuous follow-up was provided with documentation 1 week before and at 4 to 6 weeks, 3 months, and 12 months after the last treatment application. MAIN OUTCOME MEASURES: Functional parameters included best-refracted VA (Early Treatment Diabetic Retinopathy Study), and central scanning laser ophthalmoscope (SLO) scotometry and peripheral (automated perimetry) visual fields; anatomic parameters were presence of retinal edema or serous detachment (ophthalmoscopy) and tumor size (ultrasonography). RESULTS: Pretreatment VA levels ranged from 20/40 to 20/800; posttreatment levels ranged from 20/64 to 20/2000. Tumor regression with resolution of macular exudate and serous retinal detachment was obtained in all eyes. A decline in VA of 1, 3, and 10 lines, respectively, was documented in three patients. Complications included transient decompensation of vascular permeability, occlusion of retinal vessels, and ischemia of the optic nerve. CONCLUSIONS: PDT is successful in reducing tumor size and exudative activity. Vaso-occlusive effects at the level of the retina and optic nerve compromise the functional benefit. Parameters proven safe in choroidal neovascularization may be inappropriate in retinal capillary lesions of the optic nerve.     

Treatment of periocular capillary hemangiomas.

PURPOSE: To report the results of a survey of the members of the American Association of Pediatric Ophthalmology and Strabismus (AAPOS) regarding the treatment of periocular capillary hemangiomas. METHODS: A survey was delivered to the 600 members of AAPOS. Surveys were returned via facsimile. Results were collected in a computerized spreadsheet and then tabulated and analyzed. RESULTS: Of the 600 AAPOS members, 225 responded to the survey. The results showed that intralesional steroid injection is the most commonly used treatment modality for periorbital capillary hemangiomas. Oral steroids and excision were also commonly used in the treatment of these lesions. CONCLUSIONS: Further controlled studies are needed to determine which treatment modality offers the most benefit and least risk. More standardization based on these studies is necessary to improve treatment of periocular capillary hemangiomas.     

Intralesional bleomycin for the treatment of periocular capillary hemangiomas

Periocular infantile capillary hemangiomas do not always respond well to conventional treatment modalities such as systemic or intralesional corticosteroids, radiotherapy or debulking surgery. The authors describe the use of intralesional bleomycin injections (IBIs) to treat potentially amblyogenic lesions in two cases where other modalities have failed. In both cases monthly IBIs successfully cleared the visual axis of the affected eye before the age of 1 year thus preventing permanent sensory deprivation amblyopia. A total of five and nine injections, respectively, were used and no significant side effects were noted. IBI appears to be a useful alternative in the treatment of periocular capillary hemangiomas refractory to more conventional modalities.     

Retinal capillary hemangiomas and von Hippel-Lindau disease

von Hippel-Lindau disease is a multisystem familial cancer syndrome that commonly manifests in the eye as retinal capillary hemangiomas. As the earliest manifestation of the disease, these benign hamartomas can lead to secondary visual loss. Their typical clinical characteristics can lead to accurate diagnosis and appropriate treatment with either laser photocoagulation or cryotherapy enhancing one's probability of preserving vision before becoming symptomatic. Accurate diagnosis can also lead to surveillance of the various other organ systems involved in the disease such as the CNS, kidneys, adrenal glands and pancreas. This will also enable the clinician to provide genetic counseling for patients regarding the lifelong manifestations of this disease.     

Surgical excision of selected amblyogenic periorbital capillary hemangiomas

To report the successful surgical excision of well-circumscribed capillary hemangiomas of the eyelid and orbit inducing occlusion amblyopia in 2 cases with immediate improvement of the patient's symptoms. A 2-month-old girl was diagnosed with a massive, amblyogenic orbital tumor which was removed intact via an inferior transconjunctival orbitotomy after magnetic resonance imaging (MRI) revealed a well-defined mass filling the entire inferior orbit. Histopathologic examination confirmed the diagnosis of orbital capillary hemangioma. A 1-month-old girl developed occlusion amblyopia due to an enlarging subcutaneous tumor of the left upper eyelid. The discrete mass was excised via an eyelid crease approach and confirmed to be an eyelid capillary hemangioma. There were no short-term or long-term complications in either case. In both cases, immediate resolution of occlusion amblyopia and cosmetic disfiguration was achieved. The final visual acuities were 20/20 at 5 years in the first patient and 20/30 at 4 years follow-up in the second patient. Orbital and eyelid capillary hemangiomas can induce profound permanent amblyopia. If the tumor is well-circumscribed, confirmed with orbital imaging, then surgical excision, with immediate resolution of amblyogenic factors, can be considered as a treatment option.     

Surgical treatment of capillary hemangiomas causing amblyopia.

BACKGROUND: Capillary hemangiomas of the eyelids and orbit can cause refractive and occlusive amblyopia. Although oral and intralesional steroid injections are the most common treatment modalities, sometimes they are not successful. There is a paucity of information in the literature on the success of eliminating amblyogenic factors by treating these lesions with surgical resection. METHODS: Retrospective chart review of 10 patients in two pediatric ophthalmology practices who underwent surgical excision of a capillary hemangioma that was causing amblyopia and that had failed to regress with other treatment. RESULTS: Two patients had surgery secondary to pupillary occlusion, which was successful in relieving occlusion. Eight patients had surgery secondary to significant astigmatism. The average preoperative astigmatic difference between the affected and unaffected eye in five of these patients undergoing surgery before the age of 21 months was 2.15 D. The average postoperative astigmatic difference was 0.1 D. The average preoperative astigmatic difference between the affected and unaffected eye in three patients undergoing surgery after 21 months of age was 1.6 D. Surgery completely failed to reduce the astigmatism in two of these patients. The third patient had a decrease of 0.75 D of cylinder but still had a difference of 1.75 D between the two eyes postoperatively. Postoperative complications in this study included wound infection in one patient. CONCLUSIONS: Surgical excision of capillary hemangiomas that were resistant to other modes of treatment was useful in relieving pupillary occlusion and in decreasing the amount of astigmatism if performed before the age of 21 months in our series of patients. Our cases as well as the literature suggest that surgery should be performed at 13 months or earlier to reduce the amount of astigmatism.     

Therapeutic options in thyroid ophthalmopathy

One of the most important features in Graves disease is thyroid myopathy. This condition accompanies the thyroid dysfunction, that can lead to hyper-, hypo- or euthyroidism. The thyroid myopathy is the most common cause of acquired double vision in adults. This paper analyzes the evolution of thyroid myopathy, after conservative and surgical treatment. MATERIAL AND METHODS: The clinical evolution in 15 patients with thyroid myopathy was analyzed. They have been treated conservatively with systemic corticosteroids. The orbital, local antiinflammatory treatment consisted in Rx antiinflammatory therapy and retrobulbar injections with corticosteroids. Three of the patients with restrictive strabismus and diplopia were operated on. In 2 of them, with malignant exophthalmia (proptosis), orbita decompression was necessary. The surgical strategy and timing in the restrictive strabismus is analyzed. In the follow up period, the extent of the proptosis (exophthalmometry), the extraocular muscle size (orbital ultrasound) and the diplopia (Hess-Lancaster test) were monitored. The clinical evolution in one patient treated conservatively and operated on is presented in detail. DISCUSSIONS, CONCLUSIONS: The conservative treatment of the thyroid myopathy is efficient only in the acute phase. The surgical treatment should be applied when muscular fibrosis and restrictive strabismus are present. The timing of surgery is indicated after 6 months of stable ocular deviation. Adjustable surgery is the most suitable procedure for the restrictive strabismus in thyroid myopathy.     

Treatment of capillary hemangiomas causing refractive and occlusional amblyopia

PURPOSE: Capillary hemangiomas of the eyelid and orbit are treated when amblyopia secondary to anisometropic astigmatism or pupillary occlusion is present or when rapid growth of the hemangioma threatens to occlude the pupil. The goal of this study was to determine whether treatment of hemangiomas resolves or prevents occlusion or results in decrease in astigmatism. METHODS: The records of 54 patients who underwent treatment for reduction in the size of a capillary hemangioma causing amblyopia or threatened amblyopia in two pediatric ophthalmology practices were reviewed. RESULTS: Twenty-eight patients were treated for amblyopia due to anisometropic astigmatism. The average amount of pretreatment astigmatism was 2.71 D, while the average amount of post-treatment astigmatism was 0.46 D. Fifteen of these patients could be tested for optotype visual acuity and all had vision acuity of 20/40 or better. Only 1 of the 15 patients treated for threatened occlusion of the pupil developed occlusion. Six of these patients cooperated with optotype visual acuity and all had vision acuity of 20/30 or better. Eleven patients were treated for pupillary occlusion. Occlusion resolved in all cases. Of the five patients treated for occlusion who cooperated with optotype visual acuity, two had a vision acuity of 20/100 or worse. CONCLUSIONS: Treatment to reduce the size of capillary hemangiomas results in resolution of occlusion, reduction in astigmatism, and prevention of pupillary occlusion. Those with occlusion are at higher risk for severe residual amblyopia and require prompt and definitive treatment.     

光动力疗法治疗孤立型脉络膜血管瘤的疗效观察

目的观察单次光动力疗法治疗脉络血管瘤的有效性和安全性。方法回顾分析10例孤立型脉络膜血瘤患者11只眼的临床资料。10例患者中男6例，女4例，平均年龄402岁；1例双眼发病，6只左眼，5只右眼；均采用单次光动力疗法治疗，随访1～14个月,平均随访时间6.2个月。结果11只眼治疗后，全部瘤体都有不同程度萎缩，视网膜下液吸收，其中视力提高者8只眼，视力稳定者3只眼 。结论光动力疗法是治疗孤立型脉络膜血管瘤的有效治疗方法。 （中华眼底病杂志，2008，24：111-113）     

Juxtapapillary capillary hemangiomas. Clinical features and visual acuity outcomes

OBJECTIVE: To describe the clinical features, association with von Hippel-Lindau (VHL) disease and visual acuity outcomes of patients with a juxtapapillary capillary hemangioma. DESIGN: Retrospective observational case series. PARTICIPANTS: Seventy-two eyes of 68 patients identified with a juxtapapillary capillary hemangioma. Follow-up data of at least 6 months duration were available for 60 eyes. METHODS: A retrospective chart review of patients diagnosed with a juxtapapillary capillary hemangioma examined at four medical centers. MAIN OUTCOME MEASURES: Age at diagnosis, visual acuity (VA) at first examination and at last follow-up, tumor growth pattern and location, associated clinical features, type of treatment, association with VHL, and presence of peripheral hemangiomas were recorded for each patient. RESULTS: On initial examination, VA was >/=20/40 in 43 of 70 eyes (61%) and was >/=20/200 in 60 eyes (86%). At an average follow-up of 5.4 years (range, 0.5-19 years), VA of >/=20/40 was achieved in 21 eyes (35%) and >/=20/200 in 33 eyes (55%). Patients with VHL had poorer initial VA (48% vs. 70% with VA >/=20/40, and 74% vs. 93% with VA >/=20/200) and final VA (26% vs. 41% with VA >/=20/40, and 39% vs. 65% with VA >/=20/200) compared with patients without VHL. Patients with VHL more commonly were seen at an earlier age (average, 20 vs. 44 years, P: < 0.001), with bilateral (17% vs. 0%), and/or peripheral (39% vs. 0%) (P: < 0.001) tumors that more often had an endophytic growth pattern (63% vs. 22%, P: = 0.001) compared with patients without VHL. Patients selected for laser treatment generally had poorer initial (52% vs. 74% with VA >/=20/40, 79% vs. 96% with VA >/=20/200) and final VAs (18% vs. 56% with VA >/=20/40, 45% vs. 67% with VA >/=20/200) compared with patients not treated with laser. CONCLUSIONS: On long-term follow-up of patients with a juxtapapillary capillary hemangioma, the VA generally worsens. Patients with VHL and a juxtapapillary hemangioma more often present at a younger age, have tumors with an endophytic growth pattern, and have bilateral, multiple tumors. Treatment with laser photocoagulation results in variable VA outcomes.     

A review of infantile capillary hemangiomas and their current treatment modalities

Infantile capillary hemangiomas (IHs) are common, benign, high flow, vascular tumors affecting children. These lesions typically involute spontaneously leaving no long-term sequelae and require no treatment. IHs can, however, be life and vision threatening depending on their extent and location. These lesions can be addressed with a number of treatment options including corticosteroids, surgical excision, and laser. Most recently, β-blockers have shown promising results when used both systemically and topically to treat IH. Beta-blockers are an exciting new treatment option for IH and have shown promising results with few reported side effects.     

Therapeutic options in age-related exudative macular degeneration

The age-related macular disease (AMD) is the most frequent cause for blindness over 65 years in the developed countries. The incidence of this pathology (Framingham study) is: 2% (52-64 old), 11 %(65-74 old), 28%(>75 old). Our paper wants to review the therapeutic armamentarium during the last twenty years for treating Wet AMD--the most serious form of this disease.     

Therapeutic options in III. nerve paralysis

The treatment of ocular motility disorders, which occur in paralytic strabismus, presents a therapeutic challenge. The goal of treatment is to create an area of single binocular vision that is centered around the primary-gaze position. Careful analysis of the ocular motility deficit is crucial in selecting the appropriate surgical procedure. Paralytic strabismus is difficult to treat because of the incomitance of the deviation depending on the direction of gaze, respectively an increase of the deviation in the gaze with limited motility. Moreover, the possibility that horizontal and vertical components may be present, like in third nerve palsies, is another obstacle. Finally, in patients with long-stand paralysis, the ocular motility defect may have a restrictive component due to contracture of the antagonist muscle. Recognition of this phenomenon is important because any planned surgical procedure must deal with the induced restriction.     

Risk factors for amblyopia in children with capillary hemangiomas of the eyelids and orbit.

INTRODUCTION: Capillary hemangiomas are the most common orbital tumors of childhood and can cause amblyopia secondary to occlusion of the pupil, anisometropia, or strabismus. We undertook this study to describe the clinical characteristics of children with capillary hemangiomas and to propose a classification system to guide clinical treatment decisions. METHODS: A retrospective review of the records of 129 patients with 132 capillary hemangiomas in two pediatric ophthalmology practices was conducted. Hemangiomas were classified based on size. Presence of aniosometropic astigmatism, ptosis, pupillary occlusion, lid margin change, proptosis, globe displacement, and strabismus was recorded. RESULTS: Thirty-one hemangiomas measured less than 1 cm in greatest dimension and were not associated with amblyogenic factors. Seventy-five patients had hemangiomas that measured greater than 1 cm, 40 of which were associated with amblyopia. Eighteen children had diffuse hemangiomas that could not be measured and 14 of these were associated with amblyopia. Five of seven hemangiomas in six patients with PHACES syndrome were associated with amblyopia. CONCLUSION: This study is the largest review of capillary hemangiomas of the orbit and eyelids. Our findings suggest that size greater than 1 cm in largest diameter is an important predictor of amblyogenic factors and approximately half of these patients will require treatment. Diffuse hemangiomas and hemangiomas in patients with PHACES syndrome will cause amblyopia in the majority of cases.