without amblyopia (n=15) (P=.09). The malformation was Correspondence: Dr Mohney, Department of Ophthal- 2.81 times larger in the patients with amblyopia. mology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ([email protected]). Comment. In this population-based cohort of children Author Contributions: Dr Mohney had full access to all diagnosed as having periocular infantile hemangioma dur- of the data in the study and takes responsibility for the in- ing a 40-year period, amblyopia with or without strabis- tegrity of the data and the accuracy of the data analysis. mus occurred in approximately 1 in 5 children. To our Financial Disclosure: None reported. knowledge, this study is the first population-based re- Funding/Support: This study was supported in part by port on periocular infantile hemangiomas in the United Rochester Epidemiology Project grant R01-AG034676 States. The rate of amblyopia of 19% in this population from the National Institute of Arthritis and Musculo- is significantly lower than the rates in prior studies, which skeletal and Skin Diseases and an unrestricted grant from range from 43% to 76%.1-3 Research to Prevent Blindness. As stated by Robb,1 it is likely that previous studies 1. Robb RM. Refractive errors associated with hemangiomas of the eyelids and overreported the rate of amblyopia as it is often only the orbit in infancy. Am J Ophthalmol. 1977;83(1):52-58. more severe cases that are referred to ophthalmic spe- 2. Stigmar G, Crawford JS, Ward CM, Thomson HG. Ophthalmic sequelae of cialists. Given that only half of the periocular heman- infantile hemangiomas of the eyelids and orbit. Am J Ophthalmol. 1978;85 (6):806-813. giomas diagnosed at our institution were evaluated by 3. Haik BG, Jakobiec FA, Ellsworth RM, Jones IS. Capillary hemangioma of the an ophthalmologist,4 a recalculated rate that includes only lids and orbit: an analysis of the clinical features and therapeutic results in 101 cases. Ophthalmology. 1979;86(5):760-792. those children seen by an ophthalmologist would yield 4. Alniemi ST, Griepentrog GJ, Diehl N, Mohney BG. Incidence and clinical char- an amblyopia rate of 37%, illustrating the artificial in- acteristics of periocular infantile hemangiomas. Arch Ophthalmol. 2012;130 crease that occurs from reports arising solely from de- (7):889-893. 5. Holmes JM, Clarke MP. Amblyopia. Lancet. 2006;367(9519):1343-1351. partments of ophthalmology. Because this study uses a 6. Wright KW, Edelman PM, Walonker F, Yiu S. Reliability of fixation preference population-based patient cohort, a 19% rate of amblyo- testing in diagnosing amblyopia. Arch Ophthalmol. 1986;104(4):549-553. pia is likely to be a more accurate representation of the 7. Schwartz SR, Blei F, Ceisler E, Steele M, Furlan L, Kodsi S. Risk factors for am- blyopia in children with capillary hemangiomas of the eyelids and orbit. J AAPOS. general population. However, assessing vision by the fixa- 2006;10(3):262-268. tion method, the form of visual measurement used dur- ing this 40-year study, has been reported to overesti- mate the presence of amblyopia.5,6 This study is also limited by the small sample size, which, coupled with the Penetrating Ocular Trauma predominantly white race of the study patients, may limit From Airsoft Gun the generalizability of these findings to all children with periocular hemangioma. irsoft guns are recreational BB guns used for a Schwartz et al7 have reported that the size and loca- variety of popular activities, such as combat tion of the hemangioma (upper eyelid) are the most likely A games and target shooting, and as introductory factors to be associated with the development of amblyo- guns for youths. They shoot plastic ammunition at com- pia. We similarly found that the majority (88%) of the paratively low projectile energies, theoretically carrying patients with amblyopia had upper eyelid lesions. How- less potential to cause harmful injury. We report the first ever, the majority of the 43-patient cohort (86%) had up- documented case, to our knowledge, of globe penetra- per eyelid lesions,4 negating any direct association be- tion by a plastic BB shot from an airsoft gun. tween upper eyelid lesions and the development of amblyopia. However, the association with size was con- Report of a Case. A 17-year-old girl sustained a pen- firmed in this study in which the hemangiomas among etrating globe injury while she and her brother were patients with amblyopia were nearly 3 times larger than playing with an airsoft gun, unsupervised and without those in patients without amblyopia. Owing to the small protective eyewear. An airsoft BB shot out of the gun, sample size, though, this finding was not statistically ricocheted off a rock, and struck her in the right eye. She significant. was brought to the hospital with visual acuity of light Amblyopia occurred in approximately 1 in 5 chil- perception OD. On slitlamp examination, there was a dren with periocular hemangioma in this population- 3-mm limbal wound between the 7- and 9-o’clock posi- based cohort. Although the medical records were incom- tions with prolapsed uveal tissue. A computed tomo- plete, lesion size appeared to be the most significant risk graphic scan revealed a radiopaque foreign body within factor for amblyopia development. the right globe, with surrounding vitreous hemorrhage. The globe laceration was repaired emergently. Saba T. Alniemi, BS Afterward, the patient’s visual acuity remained light Gregory J. Griepentrog, MD perception with faulty projection. Adding to a very poor Nancy Diehl, BS visual prognosis were persistent findings of a reverse af- Brian G. Mohney, MD ferent pupillary defect and hypotony, with intraocular pressures less than 2 mm Hg. Nevertheless, the patient Author Affiliations: College of Medicine (Ms Alniemi), and her family desired a final attempt to improve her ocu- Division of Biostatistics (Ms Diehl), and Department of lar condition. Eight weeks after the original injury, she Ophthalmology (Dr Mohney), Mayo Clinic and Mayo underwent pars plana vitrectomy. She was found to have Foundation, Rochester, Minnesota; and Eye Institute, Medi- extensive damage including a large cyclitic membrane, cal College of Wisconsin, Milwaukee (Dr Griepentrog). total retinal and ciliary body detachment with multiple ARCH OPHTHALMOL / VOL 130 (NO. 7), JULY 2012 WWW.ARCHOPHTHALMOL.COM 944 ©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 Figure 2. Histological slide of the eye, showing that the retina is totally detached (hematoxylin-eosin, original magnification ϫ1.5). Figure 1. The horizontally cut enucleated eye in which the airsoft BB, postmortem human and porcine eyes. Similar to clinical appearing as a white sphere, is seen. reports, the most common injuries were corneal abra- sion and hyphema. No globe penetrations were recorded.5 large retinal breaks, and free-floating ciliary body pro- Our case report illustrates that airsoft projectiles have cesses. After hours of surgery, further measures to lo- the potential to cause eye injuries as devastating as those cate and remove the BB and to attempt repair of the reti- caused by metallic BBs, even by way of ricochet. We rec- nal detachment were not felt to be justified given the gross ommend that stronger cautionary warnings be given in- posterior segment disorganization and grave visual prog- dicating the possibility of blinding injury, including from nosis. A month later, the patient began experiencing con- an indirect hit. stant pain and had visual acuity of no light perception OD, so the eye was enucleated. Rohit Adyanthaya, MD The BB was later identified at pathologic examina- Timothy Chou, MD tion in the posterior segment of the enucleated globe Ali Torab Parhiz, MD (Figure 1). Histologic analysis showed total retinal de- tachment (Figure 2). Author Affiliations: Department of Ophthalmology, State University of New York, Stony Brook. Comment. A review of the literature reveals a few case Correspondence: Dr Chou, Department of Ophthalmol- series and at least 2 experimental evaluations that docu- ogy, State University of New York, Stony Brook, HSC L-2, ment the ocular effects and damage from airsoft guns. Room 152, Stony Brook, NY 11794 (timothy.chou In a series involving 9 patients, Swiss investigators de- @stonybrook.edu). tailed significant ocular injuries, including corneal abra- Financial Disclosure: None reported. sion and edema, angle recession, iridodialysis, cataract, 1. Fleischhauer JC, Goldblum D, Frueh BE, Koerner F. Ocular injuries caused hyphema, vitreous hemorrhage, and choroidal rupture. by airsoft guns. Arch Ophthalmol. 1999;117(10):1437-1439. There were no penetrating injuries, however, and no eye 2. Endo S, Ishida N, Yamaguchi T. The BB gun is equivalent to the airsoft gun 1 in the Japanese literature. Arch Ophthalmol. 2000;118(5):732. had final visual acuity worse than 20/25. Another re- 3. Ramstead C, Ng M, Rudnisky CJ. Ocular injuries associated with airsoft guns: view of 50 cases from Japan did not uncover any ex- a case series. Can J Ophthalmol. 2008;43(5):584-587. 4. Kratz A, Levy J, Cheles D, Ashkenazy Z, Tsumi E, Lifshitz T. Airsoft gun- amples of globe penetration; all but 1 patient had final related ocular injuries: novel findings, ballistics investigation, and histopatho- visual acuity better than 20/32.2 From Canada, a report logic study. Am J Ophthalmol. 2010;149(1):37-44. of 8 patients found only anterior segment injuries, the 5. Kennedy EA, Ng TP, Duma SM. Evaluating eye injury risk of airsoft pellet guns by parametric risk functions. Biomed Sci Instrum. 2006;42:7-12. most common of which was hyphema.3 Israeli authors recently compiled a list of anterior and posterior seg- ment injuries, similar to those previously reported, sus- COMMENTS AND OPINIONS tained by 59 patients.