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Wagner:
The topic we're going to discuss is the treatment of infantile hemangiomas. All three of the participants have presented or published information on the use of propranolol or other beta-blockers as a treatment for infantile hemangiomas. Before we get into the specifics of the treatment, we'll consider a case presentation of a 6-week-old child with a periocular infantile hemangioma with a cutaneous component primarily of the upper eyelid that has shown the typical progression beginning 1 or 2 weeks after birth and is now enlarging. Dr. Superstein, what do you look for to help determine the treatment or if it needs to be treated at all?
Superstein:
What I'm looking for initially is whether the lesion is amblyogenic, if it's obstructing the pupillary axis, if it's causing pressure on the globe and inducing astigmatism, or (for extremely large lesions) if it is causing strabismus.
Wagner:
Would you add anything to that, Dr. Hunt?
Hunt:
I think talking with the parents and seeing how quickly it's changing is important. If it's not amblyogenic, my approach is the same as Dr. Superstein's.
Wagner:
Dr. Guo?
Guo:
In addition to pupil occlusion, hemangioma can also cause anisometropic astigmatism, corneal exposure, or strabismus. Those are indications for early treatment.
Wagner:
Do you find patching of the uninvolved eye useful in cases where you're concerned about vision loss from amblyopia?
Hunt:
I have done that almost as a precautionary or preventative measure in some cases. Sometimes these children are too young for good fixation testing. I patched one patient with an orbital hemangioma, proptosis, and hypertropia because of the potential for amblyopia. As we began treatment, we also began patching.
Wagner:
I've seen many children with astigmatism, which often is induced in an oblique axis monocularly. I haven't put glasses on children younger than 6 months, but I have done some patching to get them through that period of time and I've only seen a few develop significant amblyopia from the astigmatism. Dr. Guo, could you comment on that?
Guo:
I agree with early patching for infants with pupil occlusion amblyopia and significant anisometropic astigmatism induced from hemangioma. Astigmatism is the more important of the concerns. The bigger the hemangioma, the more significant the anisometropic astigmatism is and...