Although infantile (capillary) hemangiomas sometimes occur as congenital eyelid lesions, most are not apparent at birth. In the typical natural course, the lesion usually develops within a few weeks or months after birth, increases in size over the first year, and gradually involutes over the next 3–7 years. Hemangiomas may also involve the orbit (see the section Vascular Tumors, Malformations, and Fistulas in Chapter 5 of this volume).
Hemangiomas are associated with a high incidence of amblyopia; therefore, treatment is recommended for patients who present with occlusion of the visual axis, anisometropia, or strabismus, as well as for lesions causing significant disfigurement. Lesions limited to the eyelid may be treated with topical timolol gel or intralesional steroids. Topical timolol gel appears to have minimal adverse effects. If vision is threatened or if there is more wide-spread or deeper orbital involvement, systemic propranolol or oral corticosteroids are typically required.
Figure 10-13 Cryptophthalmos. A, Partial cryptophthalmos seen in patient with Fraser syndrome. B, Complete cryptophthalmos.
(Part A courtesy of Ramzi M. Alameddine, MD; part B courtesy of Cat N. Burkat, MD.)
For patients who cannot take β-blockers or do not respond to timolol, intralesional steroids are considered. Intralesional steroids, which may act by rendering the tumor’s vascular bed more sensitive to the body’s circulating catecholamines, are relatively safe and effective. However, rare cases of eyelid necrosis, fat atrophy, embolic retinal vascular occlusion, and systemic adrenal suppression may occur after even a single injection. Although treatment with systemic steroids eliminates the risks of eyelid necrosis and vascular emboli, the dosage and risk of systemic adverse effects are increased.
Other treatment options may be considered for vision-compromising lesions that persist despite intervention. Topical treatment with clobetasol propionate has been reported to successfully shrink eyelid hemangiomas. Compared with oral or intralesional steroids, the topical route reduces, although does not eliminate, the risk of systemic exposure. Interferonalfa is reserved for life-threatening or sight-threatening lesions unresponsive to other forms of treatment because of the risk of serious adverse effects. Surgical excision may be used for rare well-circumscribed lesions, but it requires meticulous control of hemostasis. Use of the carbon dioxide laser as an incisional device is helpful for controlling bleeding during removal of a lesion. Topical cutaneous lasers may be used on the superficial (1–2 mm) layers of the skin to diminish the redness of a lesion, but they do not penetrate deeply enough to shrink a visually disabling lesion.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.