however , all these therapies are associated with a potential risk of damaging the overlying retina .
we report a case of circumscribed choroidal hemangioma ( cch ) in a 59-year - old man refractory to laser treatment . visual acuity was 20/200 and a serous macular detachment was present .
the cch was treated with oral propanolol , whereupon visual acuity improved to 20/20 and the macular detachment resolved without systemic or local adverse effects .
propanolol is a -blocker commonly used in cardiology that may induce endothelium vasoconstriction and inhibit endothelial proliferation .
it has been shown to be effective in infantile facial hemangiomas , and proved safe and effective for the cch in our patient .
there are two types of choroidal hemangiomas : circumscribed choroidal hemangioma ( cch ) and diffuse choroidal hemangioma ( dch ) .
cch is a rare benign , commonly asymptomatic vascular tumor which is usually diagnosed in adulthood when it becomes symptomatic with visual acuity decline , visual field defect or metamorphopsia due to exudative retinal detachment .
cch appears as an orange choroidal mass with indistinct borders , usually within the macular area .
in contrast , dch is usually evident at birth and typically occurs as part of neuro - oculocutaneous hemangiomatosis ( sturge - weber syndrome ) , but it frequently does not become manifest until adolescence .
dch appears as a diffuse orange choroidal thickening . despite this , focal regions of excessively thickened choroid may simulate cch .
choice of treatment for choroidal hemangiomas is based on tumor location , presence of subretinal fluid , extent of symptoms , and potential for visual recovery .
when vision loss occurs , different treatment options include : photodynamic therapy ( pdt ) , transpupillary thermotherapy , vascular endothelial growth factor ( vegf ) , laser photocoagulation , episcleral plaque radiotherapy , cryotherapy , external beam radiotherapy , and stereotactic radiotherapy . despite their efficacy , inducing tumor atrophy , all these treatments are associated with the potential risk of damaging the overlying retina . a new treatment has emerged for infantile hemangiomas : systemic propanolol .
it seems to be safe and effective in orbital , eyelid and facial hemangiomas in children .
a 59-year - old man with arterial hypertension ( 150/95 mm hg ) was seen in our department because of visual acuity ( va ) decline and metamorphopsia of his left eye ( os ) for 5 weeks .
we performed laser photocoagulation ( the patient refused treatment with pdt ) and 3 months later va improved to 20/100 but foveal serous detachment persisted ( fig .
2 ) . thereafter we decided to begin treatment with oral propanolol daily ( 120 mg ) .
one month later , va improved to 20/20 and serous foveal detachment disappeared ( fig .
3 ) . in addition , his arterial hypertension was under control ( 125/80 mm hg ) .
after 8 months of follow - up , both va ( 20/20 ) and the macular thickness remained stable .
their physiopathology is still poorly understood ; nonetheless , vegf and basic fibroblast growth factor ( bfgf ) have been involved in infantile hemangiomas growth . increased levels of these factors
have been detected in cutaneous hemangiomas   and vegf - receptors have been evidenced in proliferative infantile hemangiomas .
in addition , it has been shown that hypoxia - induced factors important for postnatal vasculogenesis like hypoxia - inducible factor 1 ( hif-1 ) , hif-2 and vegf are up - regulated in children with proliferative infantile hemangiomas , leading to vegf expression by endothelial cells [ 4 , 5 , 6 , 7 ] .
propranolol is a nonselective -adrenergic receptor blocker , and the adrenergic system is the major regulator of cardiac and vascular function .
capillary endothelial cells express 2-adrenergic receptors [ 7 , 8 ] which modulate the release of nitric oxide , causing endothelium - dependent vasodilatation .
in addition , -adrenergic receptor stimulation can induce modifications of signal transduction pathways of angiogenic factors such as vegf or bfgf , enhancing neoangiogenesis in ischemic events [ 7 , 8 , 9 ] .
moreover , a study of the use of -adrenergic receptor blockers for the treatment of cardiac hypertrophy revealed that carvedilol reversed levels of hif-1 and vegf to baseline values .
therefore propanolol may induce endothelium vasoconstriction , decrease expression of bfgf , hif-1 and vegf through the raf  mitogen - activated protein kinase pathway [ 4 , 8 ] and inhibit endothelial proliferation .
laser photocoagulation induces resolution of subretinal fluid , exudative retinal detachment and tumor regression ; however , subretinal fluid has a high tendency to recur , and 40% of patients require additional treatment .
radiotherapy is effective in the majority of cases , but it is associated with significant treatment morbidity .
transpupillary therapy may avoid some of the limitations of laser photocoagulation ( especially the failure to induce tumor regression ) while avoiding complications of radiotherapy .
verteporfin is an important vaso - occlusive treatment , and pdt may destroy the tumor without damaging the overlying retina and its vascularization
. if the tumor or subretinal fluid persist further , pdt re - treatments can be performed , but repeated treatments and over - treatment or overlapping pdt spots may result in delayed choroidal atrophy and fibrosis , limiting the visual outcomes [ 2 , 13 ] .
moreover , some authors suggest that it is preferable to avoid treatments within the fovea in order to decrease fibrosis and retinal pigment epithelium ( rpe ) changes .
long - term visual prognosis for patients with cch is guarded secondary to vision loss induced by subretinal fluid , macular edema , foveal distortion , and treatment side effects , like choroidal atrophy , fibrosis and rpe changes .
nowadays , eyelid and orbital infantile hemangiomas can be treated successfully with oral and topical -blockers [ 14 , 15 ] .
this may entail a new treatment for refractory hemangiomas , foveal hemangiomas , or hemangiomas the treatment of which implies high risk of scarring or rpe changes , like tumors that need pdt retreatment or hemangiomas with thin retinal detachments .
we hypothesized that this treatment would be useful in our patient , who showed no response to laser treatment , refused pdt , and presented poor va .
although the treatment with -blockers has been effective and safe in our patient , we are not able to determine whether laser treatment could have modified the final outcome .
the good visual results after treatment with oral -blockers may open a new treatment research line for cch .
 introductionseveral therapeutic approaches have been developed to treat choroidal hemangioma . 
 however , all these therapies are associated with a potential risk of damaging the overlying retina.case reportwe report a case of circumscribed choroidal hemangioma ( cch ) in a 59-year - old man refractory to laser treatment . 
 visual acuity was 20/200 and a serous macular detachment was present . 
 the cch was treated with oral propanolol , whereupon visual acuity improved to 20/20 and the macular detachment resolved without systemic or local adverse effects.discussionpropanolol is a -blocker commonly used in cardiology that may induce endothelium vasoconstriction and inhibit endothelial proliferation . 
 it has been shown to be effective in infantile facial hemangiomas , and proved safe and effective for the cch in our patient . 
 further studies are needed to confirm our observation . 
Introduction
Case Report
Discussion
Introduction
Case Report
Discussion
Disclosure Statement