A capillary hemangioma or strawberry birthmark is a benign tumor causing an abnormal overgrowth of tiny blood vessels. Capillary hemangiomas can occur on the eyelids, on the surface of the eye called conjunctiva or in the eye socket called orbit. According to some experts, 60% of the orbital capillary hemangiomas were found in the superior orbit, 16% in the inferior orbit, and 2% involving both upper and lower eyelids.
These tumors can develop as small lesions, or large masses that can cause visual impairment and systemic effects. They are one of the most common tumours in infants and one of the most common eyelid and orbital tumours of childhood. Research states that approximately 1 in 10 children are affected by capillary hemangiomas of varying severity.
Capillary hemangiomas typically occur as a solid lesion, but up to 20% of infants get multiple lesions too. Females are three times as likely as males to be affected by this tumour. Capillary hemangiomas are more frequently found in premature or low-birth babies.
They may not be present at birth, but appear within the first 6 months of life. Their size usually decreases between 12 and 15 months of age. Some of the early hemangiomas come with herald spots – tiny red macular spots created by telangectatic vessels in the skin’s superficial layers.
Mostly capillary hemangiomas relapse nearly completely by 5 or 6 years of age.
Capillary hemangiomas of the eyelid can cause amblyopia (decreased vision). In babies if the lesion exerts pressure on the surface of the eye, it causes astigmatism and the baby may develop refractive amblyopia. Astigmatism may be permanent in some cases of the tumor with upper eyelid involvement.
Occlusion amblyopia can be caused if the lesion causes the eyelid to droop to the extent that it blocks vision in the eye. If amblyopia develops in the affected eye, it can be treated with glasses or occlusion therapy using patches or atropine drops. Amblyopia is the most common complication of capillary hemangioma of the eyelid in children, with an incidence of 60%.
A capillary hemangioma in the eye socket can put pressure on the eye and result in amblyopia or strabismus. It can also press on the optic nerve which may cause optic nerve atrophy. Strabismus can occur from extraocular muscle infiltration or mechanical effect of the tumor.
Both these conditions may damage cause blindness in young children.
Usually capillary hemangiomas enlarge in size when the patients cry. Crying simulates the valsalva maneuver, which raises intrathoracic pressure, forcing deoxygenated blood into the capillary spaces of the hemangioma causing enlargement and deepening of the colour. Although this sign can be observed, it is not pathognomonic for capillary hemangiomas.
One-third of all eyelid and orbital capillary hemangiomas are diagnosed at the time of birth, and almost all are identified by six months of age.
Many capillary hemangiomas can be diagnosed on examination. But sometimes identification may require ultrasonography, computed tomography or magnetic resonance imaging for accuracy. Most tumors undergo spontaneous involution, however, some require intervention to prevent serious complications.
Some superficial capillary hemangiomas may leave some skin changes after involution, which are often cosmetically concerning. The involved skin may retain a red color or may be slightly puckered in appearance. Sometimes it may look perfectly normal depending on how completely the hemangioma has been cured.
Approximately 20 to 40 % of patients will have residual changes in the skin after involution is complete. A complete understanding of the natural history of the tumor, treatment and response to different therapies is necessary to treat these common lesions.
Capillary hemangiomas can be treated in a number of ways depending on its location, severity, and whether or not it is causing vision problems.
Propranolol is an effective medication that is used in the treatment of hemangiomas. Usually it is taken orally, but sometimes it can also be applied topically if the hemangioma is very small and thin. Since propranolol can affect heart rate and blood pressure, careful monitoring at the beginning of treatment is sometimes required and may include a brief admission to the hospital.
Steroid medications can also be used to treat hemangiomas. Steroids can stop the progression of hemangiomas by causing the blood vessels to shrink. Depending on the size and location of the hemangioma, steroids may be prescribed to be taken orally or can be injected directly into the hemangioma. It can also be applied topically on hemangioma. Steroid medications can have undesirable side effects like delayed physical growth, cataract, glaucoma and central retinal artery occlusion.
Laser treatments can sometimes be used on superficial hemangiomas to prevent growth, diminish their size, or lighten their colour.
Traditional surgery to remove hemangiomas around the eye is usually reserved for small hemangiomas that are located under the surface of the skin.