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Table. Ocular Findings Among 43 Children Diagnosed as Having Periocular Infantile Hemangioma in Olmsted County, Minnesota, From 1965 Through 2004
Table. Ocular Findings Among 43 Children Diagnosed as Having Periocular Infantile Hemangioma in Olmsted County, Minnesota, From 1965 Through 2004
1.
Robb RM. Refractive errors associated with hemangiomas of the eyelids and orbit in infancy.  Am J Ophthalmol. 1977;83(1):52-58PubMed
2.
Stigmar G, Crawford JS, Ward CM, Thomson HG. Ophthalmic sequelae of infantile hemangiomas of the eyelids and orbit.  Am J Ophthalmol. 1978;85(6):806-813PubMed
3.
Haik BG, Jakobiec FA, Ellsworth RM, Jones IS. Capillary hemangioma of the lids and orbit: an analysis of the clinical features and therapeutic results in 101 cases.  Ophthalmology. 1979;86(5):760-792PubMed
4.
Alniemi ST, Griepentrog GJ, Diehl N, Mohney BG. Incidence and clinical characteristics of periocular infantile hemangiomas.  Arch Ophthalmol. 2012;130(7):889-893
5.
Holmes JM, Clarke MP. Amblyopia.  Lancet. 2006;367(9519):1343-1351PubMedArticle
6.
Wright KW, Edelman PM, Walonker F, Yiu S. Reliability of fixation preference testing in diagnosing amblyopia.  Arch Ophthalmol. 1986;104(4):549-553PubMedArticle
7.
Schwartz SR, Blei F, Ceisler E, Steele M, Furlan L, Kodsi S. Risk factors for amblyopia in children with capillary hemangiomas of the eyelids and orbit.  J AAPOS. 2006;10(3):262-268PubMedArticle
Research Letters
July 2012

Rate of Amblyopia in Periocular Infantile Hemangiomas

Author Affiliations

Author Affiliations: College of Medicine (Ms Alniemi), Division of Biostatistics (Ms Diehl), and Department of Ophthalmology (Dr Mohney), Mayo Clinic and Mayo Foundation, Rochester, Minnesota; and Eye Institute, Medical College of Wisconsin, Milwaukee (Dr Griepentrog).

Arch Ophthalmol. 2012;130(7):943-944. doi:10.1001/archophthalmol.2012.664

Amblyopia has been reported to occur in 43% to 76% of patients with periocular infantile hemangioma.13 The purpose of this study is to describe the rate of amblyopia among a population-based cohort of children diagnosed as having periocular infantile hemangioma during a 40-year period.

Methods

The medical records of all patients younger than 19 years who were diagnosed as having periocular infantile hemangioma from January 1, 1965, through December 31, 2004, while residing in Olmsted County, Minnesota, were retrospectively reviewed after obtaining institutional review board approval. The medical records of the 43 children who met the inclusion criteria4 were reviewed for clinical characteristics of the hemangioma, including size, location, and final outcome. The ophthalmic examination results of all patients were reviewed for the presence of anisometropia, astigmatism, amblyopia, and strabismus. Amblyopia was defined as a difference of 2 or more Snellen lines between the 2 eyes (using best-corrected visual acuity) or the inability to readily and equally fixate and follow in preverbal children.

Results

Forty-three new cases (30 female [70%]) of childhood periocular infantile hemangioma were diagnosed. The incidence and demographic characteristics of this cohort have already been described.4 The Table shows the ocular abnormalities of the 43 patients, including amblyopia in 9 (21%), 1 of whom was documented to have anisometropia unrelated to the hemangioma. In the 8 patients (6 female [75%]) with amblyopia secondary to the hemangioma, the lesion was always located in the amblyopic eye, usually on the upper eyelid (n = 7 [88%]). Astigmatism (≥1 diopter [D]) at the time of diagnosis was present in 5 of the 8 amblyopic eyes (mean, 2.7 D; range, 2.0-4.0 D). The mean surface area of the hemangioma (n = 21 patients with data) was 3.08 cm2 among those with amblyopia (n = 6) compared with 1.10 cm2 for those without amblyopia (n = 15) (P = .09). The malformation was 2.81 times larger in the patients with amblyopia.

Comment

In this population-based cohort of children diagnosed as having periocular infantile hemangioma during a 40-year period, amblyopia with or without strabismus occurred in approximately 1 in 5 children. To our knowledge, this study is the first population-based report on periocular infantile hemangiomas in the United States. The rate of amblyopia of 19% in this population is significantly lower than the rates in prior studies, which range from 43% to 76%.13

As stated by Robb,1 it is likely that previous studies overreported the rate of amblyopia as it is often only the more severe cases that are referred to ophthalmic specialists. Given that only half of the periocular hemangiomas diagnosed at our institution were evaluated by an ophthalmologist,4 a recalculated rate that includes only those children seen by an ophthalmologist would yield an amblyopia rate of 37%, illustrating the artificial increase that occurs from reports arising solely from departments of ophthalmology. Because this study uses a population-based patient cohort, a 19% rate of amblyopia is likely to be a more accurate representation of the general population. However, assessing vision by the fixation method, the form of visual measurement used during this 40-year study, has been reported to overestimate the presence of amblyopia.5,6 This study is also limited by the small sample size, which, coupled with the predominantly white race of the study patients, may limit the generalizability of these findings to all children with periocular hemangioma.

Schwartz et al7 have reported that the size and location of the hemangioma (upper eyelid) are the most likely factors to be associated with the development of amblyopia. We similarly found that the majority (88%) of the patients with amblyopia had upper eyelid lesions. However, the majority of the 43-patient cohort (86%) had upper eyelid lesions,4 negating any direct association between upper eyelid lesions and the development of amblyopia. However, the association with size was confirmed in this study in which the hemangiomas among patients with amblyopia were nearly 3 times larger than those in patients without amblyopia. Owing to the small sample size, though, this finding was not statistically significant.

Amblyopia occurred in approximately 1 in 5 children with periocular hemangioma in this population-based cohort. Although the medical records were incomplete, lesion size appeared to be the most significant risk factor for amblyopia development.

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Article Information

Correspondence: Dr Mohney, Department of Ophthalmology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (mohney@mayo.edu).

Author Contributions: Dr Mohney had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Financial Disclosure: None reported.

Funding/Support: This study was supported in part by Rochester Epidemiology Project grant R01-AG034676 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and an unrestricted grant from Research to Prevent Blindness.

References
1.
Robb RM. Refractive errors associated with hemangiomas of the eyelids and orbit in infancy.  Am J Ophthalmol. 1977;83(1):52-58PubMed
2.
Stigmar G, Crawford JS, Ward CM, Thomson HG. Ophthalmic sequelae of infantile hemangiomas of the eyelids and orbit.  Am J Ophthalmol. 1978;85(6):806-813PubMed
3.
Haik BG, Jakobiec FA, Ellsworth RM, Jones IS. Capillary hemangioma of the lids and orbit: an analysis of the clinical features and therapeutic results in 101 cases.  Ophthalmology. 1979;86(5):760-792PubMed
4.
Alniemi ST, Griepentrog GJ, Diehl N, Mohney BG. Incidence and clinical characteristics of periocular infantile hemangiomas.  Arch Ophthalmol. 2012;130(7):889-893
5.
Holmes JM, Clarke MP. Amblyopia.  Lancet. 2006;367(9519):1343-1351PubMedArticle
6.
Wright KW, Edelman PM, Walonker F, Yiu S. Reliability of fixation preference testing in diagnosing amblyopia.  Arch Ophthalmol. 1986;104(4):549-553PubMedArticle
7.
Schwartz SR, Blei F, Ceisler E, Steele M, Furlan L, Kodsi S. Risk factors for amblyopia in children with capillary hemangiomas of the eyelids and orbit.  J AAPOS. 2006;10(3):262-268PubMedArticle
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