Injection of Infantile Hemangioma with Steroid

The use of propranolol in the treatment of infantile hemangiomas drastically changed our approach to these lesions.  However, at times the lesion does not respond well.  When this happens, I think it is important to revisit the diagnosis and ensure that the lesion is an infantile hemangioma.  Usually there is a dark-red or purplish hue to the lesion, and the lesion increases in size with straining or crying.  It is usually more common in premature infants and females.  And, it usually arises between 1 and 2 months of age.  You could also image the lesion with an MRI, but that involves anesthesia in a young patient.  Once you are confident of the diagnosis, if propranolol has not given a good response, you could consider injection with steroid.  I will usually do this under sedation and use a 1:1 mix of 40 mg/ml of triamcinolone and 10 mg/ml of dexamethasone. 

This is Richard Allen at oculosurg.com.  This video demonstrates an intralesional steroid injection to an infantile hemangioma that has not responded well to propranolol.  The lesion involves the upper and lower eyelid with some involvement of the orbit.  Attention is directed to the lower eyelid first.  A 27-gauge needle is used on a 3-cc syringe.  After the needle is placed into the lesion, the plunger is withdrawn to ensure that the needle has not be placed inside a blood vessel.  The needle is placed deep to the dermis.  You do not want too superficial of an injection as this will leave a visible, white, subcutaneous deposit.  Slow injection is performed.  An additional injection is given to the lesion.  Attention is then directed to the upper eyelid where the same process is performed.  Again, withdrawing the plunger, then slowly injecting.  This injection is a little more superficial than I would like.  The needle is placed into a deeper portion of the lesion and the process is repeated.  I keep a close eye on the rate of injection.  I will usually patch the eye for the day.  Follow up is performed in about one month to assess the response to the injection.