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Capillary Hemangioma

Childhood tumours are rare, but amongst them, {the} most common benign tumour is a capillary haemangioma. It is seen around {the} orbit of {the} eye, and is 3 times more common in women than in men. It accounts for 10% of all forms of haemangioma.

In this article, we shall take a brief look at this clinical condition.

Pathological considerations

A capillary haemangioma is essentially overgrowth of normal blood vessel tissues where it should not be. If one were to look at these under a microscope, it would be evident that it consists of a mixture of cells (called endothelial cells) and blood vessels. Early lesions have more cells, while advanced lesions have a lot of capillaries in {the} form of lobules. As they get more advanced, {the} capillary walls become thickened and fibrosed, resulting in occlusion of {the} vessels.

The most common site where capillary haemangioma are found is {the} upper eyelid. It could just involve {the} surface of {the} skin, but can extend to {the} tissues beneath it all {the} way to {the} orbital cavity.

Clinical signs and symptoms

Capillary haemangioma are clinically evident within {the} initially 6 months after birth. A third of {the} cases are seen at birth, and over 9 out of 10 cases are seen by 6 months. Lesions that involve just {the} skin (also called cutaneous haemangioma) appear as a red, elevated nodule, while lesions that extend under {the} skin (subcutaneous lesions) are darker. In advanced cases involving {the} orbit, {the} eyeball could protrude out. This is called proptosis.

Haemangiomas on {the} upper eyelid tend to push {the} eyelid downwards, causing a droopy eyelid (called ptosis). Patients complain of blurred vision which occurs due to change in corneal shape, astigmatism and squinting (strabismus).

On pressing gently, {the} haemangioma can change colour and have a sponge-like texture. It is visibly evident on examination.

Diagnosis

Diagnosis is primarily clinical, but imaging could be performed for further evaluation. Ultrasound can help ascertain {the} depth of involvement. CT scans can demonstrate blood flow into {the} lesion. MRI scans are also useful.

Treatment

The natural course of capillary hemangiomas is an initial growth phase followed by a regression phase. Most lesions tend to undergo involution by {the} age of 8. Treatments are offered if there is visual impairment or infection.

Medical treatment involves {the} use of steroids, taken as tablets or injected directly into {the} lesion. However, {the} long term use of steroids has a number of side effects such as osteoporosis and weight gain. In addition steroid injections can affect blood flow to {the} retina and affect {the} local skin.

Treatments that alter body immunity have also been used, but with limited efficacy. Adverse effects are high and benefits can take a long time to show.

New treatment includes {the} use of beta blocker Propranolol. This drug is often used to manage high blood pressure, but it has found to help reverse visual problems with haemangiomas. It acts by reducing {the} amount of growth factors that stimulate haemangioma growth, reducing {the} blood supply and stimulating cell death within {the} lesion. Side effects are a few, and {the} drug must be avoided if a patient has asthma.

Time Lapse photographs of patient treated with topical timolol for capillary hemangioma

Surgical treatment includes laser photocoagulation for skin lesions, and entire removal with surgery for deeper lesions. Blocking off {the} blood supply to {the} lesion using a procedure called embolisation is also useful.

Finally, any associated medical conditions that form parts of different syndromes need to be managed as well.

Conclusion

Capillary haemangioma are {the} most common benign tumour of {the} orbit. Diagnosis is straightforward, but treatments seem to be limited. Surgery appears to be {the} better option when compared to medical therapy.