Birthmarks near the eye can affect the development of children’s vision. Consultant Ophthalmologist, Manoj Parulekar discusses when to refer a child to an ophthalmologist and the different treatments available.
A haemangioma is the most common type of birthmark. It is a collection of small blood vessels forming a lump in or under the skin.
Haemangiomas can be superficial with a raised, red area in the skin referred to as strawberry mark, or they can be deeper in the skin, appearing as a bluish swelling of abnormal blood vessels underneath. Some haemangiomas are a combination of the two types.
Most haemangiomas do not cause any problems, but children who have large or growing haemangiomas near the eye should be referred to an ophthalmologist.
What causes a haemangioma?
There are several theories. One suggestion is that haemangiomas might occur due to implantation of placental tissue into the skin of the developing foetus. Haemangiomas are believed to occur in up to ten per cent of babies, and are more common in girls, premature or low birth weight babies and multiple births. Haemangiomas are not inherited.
How do they behave?
Haemangiomas typically appear in the first few weeks after birth, and grow rapidly in size and redness for the first six months, and then start regressing (shrinking and becoming less obvious) after that. Deep haemangiomas tend to appear slightly later, often up to six months after birth and can remain active for longer, often beyond one year. Most haemangiomas have regressed by seven to ten years of age. The head and neck are common locations, particularly around the eye.
Are they different from port wine stains?
Yes, they are different. Port wine stains are flat lesions that do not grow or shrink without treatment, and can sometimes be associated with glaucoma if present around the eye.
How can haemangiomas affect vision?
Haemangiomas occur when a young child’s vision is developing rapidly. A haemangioma near the eye can sometimes press and alter the shape of the eye (astigmatism), resulting in a blurred image. The brain then ignores the blurred image, preferring to “pay attention” to the clearer image from the unaffected eye. This can lead to the eye near the haemangioma becoming “lazy”. Similarly, if the haemangioma causes a droopy eyelid partially covering the pupil (ptosis), it deprives the child of the usual visual stimulation and causes “lazy eye” (amblyopia).
This can be treated by forcing the brain to use the lazy eye, by patching the good eye for several hours a day or blurring its vision with eye drops. This treatment is really important to ensure that vision develops well in both eyes.
Treatment of haemangiomas
Propranolol is a medicine for reducing blood pressure that has been in use for several decades. More recently (since 2008) it has been shown to be very effective in treating growing haemangiomas and is now the mainstay of treatment. It works on the chemicals that promote the growth of abnormal blood vessels, and is very safe and effective. The effect is seen within days to weeks, and treatment is usually required for six to 18 months.
Propranolol is prescribed as a liquid medicine to be taken orally, twice daily, and is available in several concentrations. Common side effects include cold hands and feet and diarrhoea, and less common side effects are night terrors, asthma (very rare) or low blood sugar. Low blood sugar can be avoided by skipping a dose if food intake is reduced for any reason.
In the past, steroid injections into the haemangioma or oral steroids were used to treat haemangiomas, but these approaches are rarely used nowadays.
What about surgery?
Surgery might be appropriate for well localised haemangiomas or for the loose skin and fibrofatty tissue that is sometimes left behind after large haemangiomas have been treated with Propranolol.
Where is treatment offered?
Propranolol treatment for haemangiomas around the eye is now offered in most hospital eye departments in the United Kingdom, and is usually supervised by the paediatric ophthalmologist, an ophthalmologist who specialises in treating children’s eyes.
It is important to monitor how clearly a child can see at a distance and close up (their visual acuity), check whether the eye is bending light to give the sharpest image possible (the refraction) in order to detect a lazy eye, and then prescribe glasses, patching or both as needed.
Haemangiomas elsewhere on the body are treated by dermatologists or plastic surgeons. Larger centres such as Birmingham Children’s Hospital also offer surgery for haemangiomas, usually by a paediatric ophthalmic surgeon, or oculoplastic surgeon, or plastic surgeon.
The author is a consultant ophthalmologist at Birmingham Children's Hospital. This article was first published in issue 50 of Insight, RNIB's magazine for parents and professionals supporting blind and partially sighted children and young people.