Norra MacReady

April 04, 2011

April 4, 2011 (San Diego, California) — Children with port wine stains and choroidal hemangiomas characteristic of Sturge-Weber syndrome who are treated with pulsed-dye laser therapy and the prostaglandin bimatoprost might have an unusually high risk for exudative retinal detachment, researchers announced here at the American Society of Pediatric Ophthalmology and Strabismus 37th Annual Meeting.

Somehow, those 4 factors — port wine stain, choroidal hemangioma, use of the pulsed-dye laser, and treatment with bimatoprost — converge into a "perfect storm" that might set a child up for exudative retinal detachment, Samantha Harding, MBBS, a fellow in pediatric ophthalmology at the Great Ormond Street Hospital for Children, London, United Kingdom, told Medscape Medical News. The exact culprit is unclear, but no cases of retinal detachment have occurred since she and her colleagues disrupted the combination by discontinuing the bimatoprost drops.

The first hint of a problem came when "we got a fairly rapid succession of 4, and then 5, children who had exudative retinal detachment. That made us sit up and take notice," she explained.

To investigate further, she and her colleagues conducted a retrospective case-note review of all the patients in their department with port wine stain who underwent pulsed-dye laser treatment. Those records were then cross-referenced with the pharmacy records of all patients receiving bimatoprost drops.

The pharmacy records identified 23 patients with port wine stain who had used bimatoprost. Of those patients, 19 also had choroidal hemangioma and had undergone pulsed-dye laser treatments, and 5 of those 19 patients developed exudative retinal detachment. Retinal detachment did not occur in the 4 patients who were not treated with the laser. All of the children were taken off bimatoprost, and in 1 case, the retina spontaneously reattached.

Children with Sturge-Weber syndrome are at high risk for retinal detachment to begin with, in part because of uveoscleral outflow against choroidal and episcleral hemangioma, increased episcleral pressure, and possibly exudative change from the hemangioma itself, Dr. Harding explained during her poster presentation. How the laser therapy might increase that risk is unclear, especially because it penetrates only to a depth of 1 to 4 mm, and eye shields are used during all treatments.

"But we know from 1 paper that the pulsed-dye laser can lower intraocular pressure by 0.75° to 3.00°. That is not thought to be clinically significant, but it does happen. But we don't really have a clinical theory as of yet. We can't point the finger at any 1 factor."

"This is a good observation and a lovely study. I don't think most of us are aware of this phenomenon," said Stephen Christiansen, MD, chair of ophthalmology and pediatrics at Boston University School of Medicine, Massachusetts. Dr. Christiansen, who was not involved in this study, suggested that Dr. Harding might consider adding retinal detachment to the informed consent.

They have not done that yet, Dr. Harding said. However, she concluded, although the laser alone is probably not the problem, physicians should be extra vigilant when combining it with bimatoprost in children with port wine stain and choroidal hemangioma. "We need to be safe because we don't want to be sorry."

Dr. Harding and Dr. Christiansen have disclosed no relevant financial relationships.

American Society of Pediatric Ophthalmology and Strabismus (AAPOS) 37th Annual Meeting: Poster 11: Presented March 31, 2011.

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