Clinical Features, Prognostic Factors, and Treatment Interventions for Ulceration in Patients With Infantile Hemangioma.

Importance: Ulceration is a common complication of infantile hemangioma (IH), which leads to substantial morbidity. Ulceration in IH has not been systematically studied since the advent of ß-blocker therapy for IH. Objectives: To examine treatment interventions used for ulceration in IH and identify clinical prognostic indicators of healing time. Design, Setting, and Participants: A retrospective, multicenter cohort study was conducted on 436 consecutive patients with a clinical diagnosis of ulcerated IH and available clinical photographs. Patients receiving care at tertiary referral centers evaluated between 2012 and 2016 were included; statistical and data analysis were performed from February 7 to April 27, 2020. Exposures: Clinical characteristics, treatment interventions, course, complications, and resource use were analyzed. Treatment interventions for ulceration in IH included local (wound care, topical), systemic (ß-blocker, corticosteroids), and procedural (pulsed-dye laser). Main Outcomes and Measures: The primary end point was time to complete or nearly complete ulceration healing. Clinical characteristics were analyzed to determine the responses to most common interventions and prognostic factors for healing of ulceration. Results: Of the 436 patients included in the study, 327 were girls (75.0%); median age at ulceration was 13.7 weeks (interquartile range, 8.86-21.30 weeks). The median heal time was 4.79 weeks (95% CI, 3.71-5.86 weeks) with wound care alone, 5.14 weeks (95% CI, 4.57-6.00 weeks) with timolol, 6.36 weeks (95% CI, 5.57-8.00 weeks) with a systemic ß-blocker, and 7.71 weeks (95% CI, 6.71-10.14 weeks) with multimodal therapy. After adjusting for IH size, a dose of propranolol less than or equal to 1 mg/kg/d was associated with shorter healing time compared with higher propranolol doses (hazard ratio, 2.04; 95% CI, 1.11 to 3.73; P = .02). Size of the IH was identified as a significant prognostic factor for healing time in multivariable analysis. Increasing size of IH portends a proportionately longer time to heal of the ulceration. Conclusions and Relevance: Despite the use of ß-blockers, this cohort study found that a subset of patients with IH ulceration continued to experience prolonged IH healing times. Larger IH size appears to be a poor prognostic factor for time to heal. For patients requiring systemic therapy, initiation of propranolol at lower doses (≤1 mg/kg/d) should be considered.

Enhanced Percutaneous Delivery of Beta-Blockers Using Thermal Resurfacing Drug Delivery System for Topical Treatment of Infantile Hemangiomas.

BACKGROUND: Infantile hemangiomas (IHs) are the most common vascular tumors in children. In the past few years, topical beta-blockers (bBs) have been reported to be an effective treatment of superficial IHs. OBJECTIVE: We sought to evaluate the clinical effectiveness and safety profile of enhanced percutaneous delivery of bBs for the treatment of IH. METHODS: A retrospective study of all cases of IHs treated with enhanced percutaneous delivery of bBs between 2018 and 2019 was performed. Epidemiologic, clinical, and treatment data, including effectiveness score and safety, were reviewed. RESULTS: The study included 11 patients with a total of 11 IHs. Of the total number of IHs, 7 (63.7%) showed a good response to treatment and 4 (36.3%) had a partial response; thus all patients (100%) had good or partial response to treatment. No systemic or local adverse effects were reported. LIMITATIONS: This is an uncontrolled retrospective study. CONCLUSION: Enhanced percutaneous delivery of bBs is a safe and efficient topical therapy for IH.

[Clinical analysis of juxtapapillary retinal capillary hemangioma].

Objective: To discuss the clinical features and treatment of juxtapapillary retinal capillary hemangioma (JRCH). Methods: Retrospective study of the clinical data of 6 patients (7 eyes) who were diagnosed with JRCH, among which 2 eyes were treated by laser therapy (thermotherapy TTT or photodynamic therapy PDT), 2 eyes were treated by intravitreal anti-VEGF injection, 2 eyes with vitreous hemorrhage were treated with vitrectomy (PPV)+ anti-VEGF, and 1 eye was untreated. Results: In the 6 cases, the gender ratio of male to female is 2∶1 with average age of 46 years. Four eyes were associated with macular edema(57.1%), vitreous hemorrhage(n=2, 28.6%), and epiretinal membrane(n=1, 14.2%) in the initial examination. Three patients were associated with von Hippel-Lindau(VHL). During the follow-up period, the visual acuity of the 2 patients treated by TTT decreased. Among the 2 eyes treated by anti-VEGF, the visual acuity of 1 eye associated with macular edema increased, and the visual acuity of 1 eye with macular epiretinal membrane did not change significantly, the visual acuity of both 2 eyes treated by PPV+anti-VEGF improved, the vision of the 1 eye untreated appeared to be stable. Conclusions: Juxtapapillary retinal capillary hemangioma is the orange or red vascular hamartomas that occur on or adjacent to the optic nerve head. It is often associated with macular edema, vitreous hemorrhage, and local subretinal effusion. Symptomatic treatment of complications can effectively improve the visual acuity of patients, while long-term follow-up observation should be organized for patients without complications, laser treatment appears to be ineffective. (Chin J Ophthalmol, 2019, 55:609-615).

Combination of Sclerotherapy and Dual-Wavelength Laser in the Management of Infantile Hemangiomas in Chinese Infants.

OBJECTIVE: To evaluate the efficacy and safety of combination therapy with sclerotherapy and dual-wavelength pulsed dye laser (PDL) & Nd:YAG for infantile hemangiomas (IHs). PATIENTS AND METHODS: Fifty-nine patients with IH received treatment with sclerotherapy and dual-wavelength PDL & Nd:YAG treatment at 4-week intervals. Observers assessed the size and color of IH using a size rating scale and color rating scale before and after treatments. RESULTS: The study showed that IH improved significantly after several sessions of treatment. Sclerotherapy reduced the size of IH, whereas dual-wavelength laser lightened the color of IH. No serious adverse effects occurred. CONCLUSION: Combined sclerotherapy and dual-wavelength laser treatment is an effective and safe option for IH.

State-of-the-art lasers and light treatments for vascular lesions: from red faces to vascular malformations.

Notable milestones in the treatment of vascular lesions have been achieved over the past century. Many cutaneous vascular lesions can be successfully treated with lightbased devices. In this review, we will discuss the treatment of port-wine birthmarks, lymphatic malformations, infantile hemangiomas, rosacea, venous lakes, pyogenic granulomas, cherry angiomas, and angiofibromas using lasers, total reflection amplification of spontaneous emission of radiation, intense pulsed light, and photodynamic therapy. In addition, for several of these diagnoses, we will review medical therapies that can be combined with light-based devices to provide enhanced results.

En face mode of swept-source optical coherence tomography in circumscribed choroidal haemangioma.

PURPOSE: To describe the findings in circumscribed choroidal haemangioma (CCH) using en face swept-source optical coherence tomography (SS-OCT). METHODS: En face images were obtained employing DRI-1 Atlantis OCT (Topcon, Tokyo, Japan), using a three-dimensional volumetric scan of 12×9 mm. Images were obtained from the retinal pigment epithelium to 1000 µm in depth of the tumour. RESULTS: Twenty-two eyes from 22 patients with the clinical diagnosis of CCH were included. In 20 eyes (90.9%), a characteristic pattern was visualised in the en face image across the vascular tumour. A multilobular pattern, similar to a honeycomb, with hyporeflective, confluent, oval or round areas corresponding with the lumen of the tumour vascular spaces, and hyper-reflective zones, which may represent the vessels walls and connective tissue of the tumour. Ten eyes (45.4%) showed a hyper-reflective halo surrounding the tumour. Seventeen tumours (77.2%) showed small diameter vessels at the inner zone and larger vessels in the outer area. Twelve patients (54.5%) had previously received treatment (photodynamic therapy, transpupillary thermotherapy, dexamethasone intravitreal implant or brachytherapy with ruthenium-106). No differences were found between treated and untreated patients in any of the measured parameters. CONCLUSIONS: En face SS-OCT is a rapid, non-invasive, high-resolution, technology, which allows a complementary study to cross-sectional scans in CCH. A characteristic multilobular pattern, with a hyper-reflective halo surrounding the tumour, was found in en face SS-OCT images. No morphological differences were found between naïve patients and patients who received previous treatment.

[Combined transscleral and transpupillary thermotherapy in large vasoproliferative retinal tumors].

Three cases (two patients) of large vasoproliferative retinal tumor treatment by an original method, which includes intraoperative non-contact transscleral thermotherapy and subsequent transpupillary thermotherapy, are described. Positive anatomical results were achieved in all three cases.

Interventions for infantile haemangiomas (strawberry birthmarks) of the skin.

BACKGROUND: Infantile haemangiomas (also known as strawberry birthmarks) are soft, raised swellings of the skin which are usually uncomplicated and tend to regress spontaneously over time. Some haemangiomas occur in high-risk areas or can develop complications; therefore, intervention may be necessary. Various interventions have been proposed, but it is unclear whether any of these interventions are effective. OBJECTIVES: To assess the effects of interventions for infantile haemangiomas. SEARCH STRATEGY: We searched the following databases up to March 2011: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (Clinical Trials) in The Cochrane Library, MEDLINE, EMBASE, PsycINFO, AMED (Allied and Complementary Medicine), LILACS (Latin American and Caribbean Health Science Information database), CINAHL, and reference lists of articles. We also searched online trials registries for ongoing trials and grey literature. SELECTION CRITERIA: We included children with haemangiomas. DATA COLLECTION AND ANALYSIS: Two authors independently screened titles, abstracts, and the full text of publications; extracted data; and assessed risk of bias. MAIN RESULTS: We included 4 studies with a total of 271 participants.One randomised controlled trial (RCT) compared pulsed dye laser (PDL) therapy versus the 'wait and see' approach. At one year PDL was significantly more likely to result in complete clearance. The risk ratio (RR) was 6.10 (95% CI [confidence interval] 1.89 to 19.64); however, there was no difference when clearance was defined as 'complete or minimal residual signs'. Redness was significantly less pronounced in the PDL group, but no differences were seen for height or surface area. Significant increases in atrophy and skin hypopigmentation were seen in the PDL group.One very old RCT assessed radiation versus mock-radiation; there was no significant difference in clearance at six years (RR 1.08, 95% CI 0.63 to 1.87) between the groups, irrespective of the size of the haemangioma and the skin colour.In one small RCT there was a significantly greater reduction in size of the haemangioma with oral prednisolone compared to intravenous methylprednisolone at three months (mean difference [MD] was 58 mm [95% CI 29.24 to 86.76]), and one year. Similar adverse events occurred in both groups.In another small RCT there was a significant reduction in the surface area of the haemangioma with bleomycin compared to the control (RR 21, 95% CI 1.34 to 328.86). AUTHORS' CONCLUSIONS: This review has found limited evidence from individual RCTs to support some of the existing interventions (corticosteroid and PDL) for infantile haemangiomas. There is a need for further high-quality RCTs to validate the findings from these studies, and RCTs to assess the effect of other treatments, in particular relating to propranolol.

[Capillary hemangioma of the retina in cases of von Hippel-Lindau syndrome. New therapeutic directions]. / Kapilläre Hämangiome der Netzhaut beim Von-Hippel-Lindau-Syndrom. Neue Therapieansätze.

Thermal photocoagulation of small peripheral angiomas is the treatment of choice for capillary hemangiomas in patients with von Hippel-Lindau disease. Larger peripheral angiomas are better treated with beta-ray brachytherapy resulting in improved results in terms of local tumor control and the side effects of treatment. Photodynamic treatment is an alternative option in the management of capillary hemangiomas of the retina. Further improvement of the treatment results of photodynamic therapy may be achieved by combination with intravitreal drugs. External beam radiation using either stereotactic techniques or proton radiation must be considered as experimental. The treatment of juxtapapillary angiomas is still a therapeutic dilemma. Vitreoretinal surgery should be confined to advanced stages with tractional detachment or when no other treatment option is available to salvage the eye.

Transpupillary thermotherapy in the management of circumscribed choroidal hemangioma.

Laser photocoagulation and various radiation therapy methods have been used in the treatment of circumscribed choroidal hemangioma that produce visual loss. Recently, transpupillary thermotherapy has been employed in the management of choroidal hemangioma. Thirty-six cases of choroidal hemangioma treated with transpupillary thermotherapy are reviewed. Twenty-eight cases were reported in the literature and 10 cases were managed by the author. Transpupillary thermotherapy has been used as a primary treatment (36 cases) or secondary treatment (2 cases) for choroidal hemangioma. The goal of transpupillary thermotherapy is to achieve resolution of exudative detachment of the fovea and improvement of vision. In all eyes the foveal detachment subsided. In 26 eyes having pretreatment visual acuity >or=0.05 (20/400), the visual acuity increased in 20 (77%) eyes and remained unchanged in 6 (23%) eyes. After transpupillary thermotherapy, 16 (42%) cases showed complete regression, 20 (53%) demonstrated partial regression, and in 2 (5%) there was no change in tumor thickness at follow-ups ranging from 2 to 44 months. Complications of transpupillary thermotherapy of choroidal hemangioma included cystoid macular edema (3 eyes), preretinal fibrosis (2 eyes), focal iris atrophy (3 eyes), and retinal vascular occlusion (1 eye). Although the follow-up in many studies is limited, transpupillary thermotherapy has not been associated with any significant complications.

Transpupillary thermotherapy for retinal capillary hemangioma in von Hippel-Lindau disease.

Retinal capillary hemangiomas are a common manifestation of von Hippel-Lindau disease. We report the treatment of a peripapillary retinal capillary hemangioma in the left eye of a 30-year-old woman with this condition, using infrared diode laser transpupillary thermotherapy (TTT). The hemangioma was evaluated before and after treatment by ophthalmoscopy, fundus fluorescein angiography, and Doppler ultrasonography. Infrared diode laser TTT was delivered over 3 sessions during a period of 22 weeks, resulting in an improvement in visual acuity from counting fingers to 6/24 and a marked decrease in exudates surrounding the hemangioma. Doppler ultrasonography demonstrated a decrease in intralesional blood flow from 7 cm per second to less than 3 cm per second, together with a decrease in the size of the lesion. Infrared diode laser TTT provides a useful modality in the treatment of retinal capillary hemangiomas, and may be particularly favorable for peripapillary lesions because of its relatively nondestructive characteristics.

Transpupillary thermotherapy for circumscribed choroidal hemangiomas.

PURPOSE: Various treatments have been described for circumscribed choroidal hemangiomas. We present our results with transpupillary thermotherapy (TTT) with infrared laser that indicate that the therapy is a new, effective treatment for this pathologic condition. DESIGN: Noncomparative, prospective, interventional case series. PARTICIPANTS: The treatment and follow-up of eight eyes of eight patients with circumscribed choroidal hemangiomas are presented. Each case was treated when the visual acuity (VA) decreased because of serous retinal detachment that affected the macula. METHODS: Infrared diode laser was used at 810 nm and power between 800 and 1200 mW with a beam diameter of 2 or 3 mm depending on the diameter of the hemangioma, with 3 to 6 minutes of exposure time. MAIN OUTCOME MEASURES: The final VA, the presence of serous subretinal fluid, funduscopic appearance of the tumor, and the degree of hyperfluorescence observed during fluorescein angiography were the main parameters. RESULTS: In all eight cases, total reabsorption of the serous retinal detachment was achieved after one or repeated applications of TTT. Mild choroidal atrophy and minimal hyperpigmentation of the retinal pigment epithelium were observed in the treated eyes. CONCLUSIONS: TTT can be considered an acceptable therapeutic option for choroidal hemangiomas and serous retinal detachment, and we believe that the role of this therapy will expand in the management of these patients.

Therapeutic options for capillary papillary hemangiomas.

PURPOSE: To describe the results and therapeutic complications of treatment of papillary capillary hemangiomas over the last 13 years. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Five cases of unilateral capillary papillary hemangiomas were reviewed. Three patients had von Hippel-Lindau disease, and two had no associated familial or systemic disease. METHODS: Two patients were treated with argon green laser, one patient received argon green and diode photocoagulation, and two patients underwent argon green photocoagulation and diode transpupillary thermotherapy (TTT); two eyes also underwent vitreoretinal surgery. Follow-up ranged from 1 to 13 years. MAIN OUTCOME MEASURES: The presence of exudative retinal detachment associated with the activity of the hemangioma and the visual acuity were the two main parameters. RESULTS: Prompt argon green laser treatment was the most effective therapy; -II was ineffective. Vitreoretinal surgery, transscleral drainage, and argon endolaser photocoagulation in one case resolved bullous retinal detachment secondary to tumor exudation. Pretreatment visual acuity (VA) levels ranged from 20/25 to counting fingers; posttreatment VA levels ranged from 20/25 to light perception. CONCLUSIONS: If left untreated, papillary hemangiomas may evolve to exudative retinal detachment and marked VA decreases. Although we have not established an ideal therapy, we recommend appropriate treatment on diagnosis. Close follow-up and multiple treatments with argon laser are likely the best therapeutic course.

[Capillary hemangioma, a rare neoplasia in a calf]. / Kapilläres Hämangiom, eine seltene Neoplasie beim Kalb.

A calf with a dark red, cauliflower-like mass in its oral cavity was referred to our clinic. Histopathologic examination of this mass revealed a capillary hemangioma. A combination of thermotherapy and cryosurgery was used in the treatment of this tumor. Healing was followed for one year.