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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%. As stated by Robb, 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, 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. 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 al 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, 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 populationbased cohort. Although the medical records were incomplete, lesion size appeared to be the most significant risk factor for amblyopia development.

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