Surgical Management of Amblyogenic Periorbital Hemangiomas:
Indications and Outcomes
Jugpal S. Arneja, MD, FRCSC and John B. Mulliken, MD.
Background
Periorbital hemangiomas present in various forms, from a well-localized to a
more extensive tumor. Often, simple observation is all that may be required,
however, lesions in the periorbital region can cause irreversible amblyopia
secondary to obstruction of the visual axis, optic nerve compression, strabismus,
or most commonly, astigmatism and anisometropia from corneal deformation.
The treatment of these lesions has evoked much controversy in the literature.
The purpose of the present report is to determine the efficacy and safety of early
surgical excision of amblyogenic periorbital hemangiomas.
Methods
We reviewed all patients with periorbital hemangiomas managed by surgical
excision at Children's Hospital of Michigan and Children's Hospital Boston over a
five-year period. Indications for surgical excision were (1) a well-localized lesion
causing (2) obstruction of the visual axis and/or (3) corneal deformation with
greater than two diopters of astigmatism. Surgical technique involved excision or
debulking of the hemangioma via an upper lid, supratarsal crease incision, and if
necessary, reinsertion or advancement of the levator palpebrae superioris
muscle (Figure 1, A-F). Inclusion criteria for review included patients treated
surgically with a minimum six-month follow-up interval, and complete preoperative and post-operative ophthalmologic assessments.
Figure 1: Surgical technique.
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Results
Twenty-six patients met the inclusion criteria, with a mean hemangioma onset
age of 1.0 months and mean operative age of 5.9 months. The majority of
hemangiomas were subcutaneous and located in the upper lid, causing
astigmatism (mean 3.09 diopters, range 1 to 5) in 88% of patients or
blepharoptosis with obstruction of the visual axis in 46% of patients. Prior
treatment in 54% of patients included corticosteroids, and/or patching.
Postoperatively, a statistically significant improvement in the degree of
astigmatism (mean 0.99 diopters, range 0 to 3) was observed (p-value < 0.001,
Wilcoxon Rank-Sum Test). Reinsertion or advancement of the levator palpebrae
superioris was required in 31% of patients. The mean follow-up interval was 31
months and complications were at a minimum. One patient had a local
recurrence, not significant to warrant re-excision, one patient had residual
astigmatism, and two patients exhibited residual blepharoptosis. Figures 2 (A, B)
and 3 (A, B) represent patients managed with surgical excision, preoperatively
and one year post-operatively.
Figures 2 and 3: Surgical results (pre-operatively and one-year post-operatively)
Conclusions
To prevent potentially irreversible amblyopia in patients with periorbital
hemangiomas, our results suggest early surgical excision to be efficacious, with
infrequent complications, and a statistically significant improvement in the
severity of corneal astigmatism. We advocate resection for well-localized
periorbital hemangiomas, causing major refractive error with likelihood for the
development of amblyopia, preferring to avoid in the majority of instances,
intalesional corticosteroid injection, with its well-documented complication profile.
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