- Email: [email protected]
Intercanthal and interpupillary distance in the black population
Intercanthal and interpupillary the black population Walter K. Murphy, DEPARTMENT
distance in
DDS,a and Daniel M. Laskin, DDS, MS,h Richmond,
OF ORAL
AND
MAXILLOFACIAL
SURGERY,
MEDICAL
COLLEGE
Va, OF VIRGINIA
lntercanthal distance is an important measurement in the evaluation of congenital deformities and posttraumatic telecanthus. In this study 100 black patients (71 female and 29 male) were measured for intercanthal and interpupillary distance. For the overall group the mean intercanthal distance was 33.9 + 3.0 mm; previous studies of white persons and mixed populations indicate an average of 32 + 3 mm. The mean interpupillary distance for this study was 63.7 r 3.7 mm; previous studies indicate an average of 63 k 3 mm. This study suggests that the intercanthal and interpupillary distances in blacks are similar to findings of previous studies on whites and mixed populations.
(ORALSURGORALMEDORAL PATHOL1990;69:676-80)
I
ntercanthal distance is an important measurement in the evaluation of congential deformities and posttraumatic telecanthus. Previous studies have been performed on the white population’, 2; however, no studies have focused exclusively on the black population. The purpose of this study was to determine the intercanthal distance and the interpupillary distance for the black population and to determine whether differences exist between these data and those from previous studies on other populations. METHODS
One hundred black patients from the Medical College of Virginia (71 female and 29 male; mean age, 46 years) with no prior history of trauma or congenital anomaly were measured for intercanthal and interpupillary distance. Measurements were made with a Miltex caliper rule (Miltex Inc., Lake Success, N.Y.) to the nearest 0.5 mm. Intercanthal distance was measured between the median angles of the palpebral fissures, and interpupillary distance was measured between the midpoint of the pupils. RESULTS
For the overall group the mean intercanthal distance was 33.9 -t 3.0 mm (range, 28 to 43.5 mm) (Table I). The difference between men (35.7 f 3.7
7/12/10358 676
mm) and women (33.1 ? 2.3 mm) was statistically significant (p < 0.0001, unpaired t test). Mean interpupillary distance for the group was 63.7 f 3.7 mm (range, 55 to 73 mm) (Table I). The difference between men (66.3 +- 3.6 mm) and women 62.6 +3.2 mm) was statistically significant (p < 0.0001, unpaired t test). DISCUSSION
Intercanthal and interpupillary distances are integral measurements in the evaluation of facial trauma and may aid in the early identification and diagnosis of numerous congenital craniofacial syndromes. In addition, these measurements are essential in the treatment planning and surgical correction of congenital and posttraumatic deformities. Several previous studies have been conducted on white and racially mixed groups of varying ages;however, none have focused exclusively on the black population. This study found the intercanthal and interpupillary distance of the black population to be similar to that reported in previous studies of white and mixed populations (Tables II and III). Gunther3 found the normal intercanthal distance in whites to range between 25.5 and 38.5 mm. Studying a mixed European population, Waardenburg4 found the intercanthal distance to average 33 to 34 mm in the male and 32 to 33 mm in the female. In the adult population portion of their study, Laestadius et al.’ found the distance to measure 30 + 2.5 mm in males and 30 -t 3.0 mm in female. In a study of mixed
Intercanthal
Volume Number
69 6
Table
I. Mean intercanthal GOUp
lntercanthal Combined Male Female Interpupillary Combined Male Female /CD,
lntercanthal
and interpupillary __-__ ICDor IPD
100 29
33.9 35.7
0.302 0.68 1
3.0 3.1
71
33.1
0.279
2.3
100
63.7
0.368
3.1
29 71
66.3 62.6
0.67 1 0.374
3.6 3.2
.--__~-d~!&nce,
[PD.
intcrpupillnry
distance
677
distance in the black population
No. of patients
(mm)
and interpupillary
SE (mm)
SD (mm) -----
~- -;zz%~
0.000
0.0001
-_--
1
28-43.5
55-73
__.-~-
distance.
populations, Feingold and Bossert’ found the overall intercanthal distance to be 35 mm. Freihofer6 found an average intercanthal distance of 31.2 + 2.5 mm, with no statistical difference between the sexes. According to the accumulated data from the previous studies, the average intercanthal distance is approximately 32 mm, with an SD of 3 mm. The results from our study of the black population fall within this range, although the figures, especially for males, appear to be slightly greater than those reported in some studies. Lucas and Pryor found the average interpupillary distance to be 59 mm (male SD + 4.4; female SD * 5.2). Studying a mixed European population, Waardenberg4 found the interpupillary distance to average 65.3 mm for males and 62.7 mm for females. Feingold and Bossert5 found the overall average to be 63 mm and, in studies of Japanese, Mexican, and white groups, Pryor found the average to range between 60 and 65 mm. The average interpupillary distance from these studies is approximately 63 mm, with an SD of 3 mm. The results of our study on the black population also fall within this range. TELECANTHUS
The intercanthal distance is of primary importance in the evaluation of facial trauma and congenital deformities. This distance is maintained by the median canthal ligament, which connects the tarsal plates and palpebral structures to the median orbital structures. Telecanthus is an increase in the distance between the median canthi. DeMyers differentiates between primary and secondary telecanthus. Primary telecanthus is caused by an increase in soft tissue with a normal interpupillary and interbony distance; secondary telecanthus is the result of an increase in interpupillary and interbony distance, as is found in hypertelorism, with subsequent widening of the soft
tissue intercanthal distance (Fig. 1). Primary telecanthus is often a result of trauma. Disruption of the median canthal ligament involves either detachment of the bone anchoring the ligament or transection of the ligament and can be associated with direct trauma to the nasoethmoidal structures or Le Fort II or Le Fort III fractures. Posttraumatic telecanthus is reported to occur in 12% to 20% of all midface fractures9 Forces from the orbicularis oculi and levator palpebrae muscles pull the unsecured ligament anteriorly and laterally, resulting in the characteristic rounding of the median canthal soft tissues and shortening of the horizontal palpebral fissure.2, t l Epiphora results from either detachment of Horner’s muscle, with subsequent failure of the puncta to approximate the globe, or direct injury or kinking of the nasolacrimal apparatus. In addition, detachment of Horner’s muscle results in laxity of the eyelids, with increased visibility of the sclera.9 Evaluation of traumatized patients for telecanthus involves measurements and comparisons with known norms for the region. If assessment is difficult because of tissue damage or posttraumatic edema, continuity of the median canthal ligament can be tested by placing lateral traction on the upper eyelid; this tension is transmitted through the tarsal plates to the ligament, which can then be visualized or palpated.‘e In the absence of trauma, evaluation of the intercanthal distance should take into account common variations in median canthal soft-tissue anatomy, as well as congenital deformities occurring as isolated entities or components of various syndromes. Examination of the characteristics of the intercanthal and ocular adnexa is important in the identification of numerous craniofacial anomalies. Proper diagnosis can aid the clinician in anticipating late-appearing associated defects, such as the progressive exophthalmos associated with Apert’s and Crouzon’s syn-
678
Murphy
and Laskin
Table
Ii. Previous reports of intercanthal -.~
ORAL
Gunther3 Waardenburg4 Laestadius et al.’ Pryor’
Feingold Freihofer6
and Bossert5
Date
Population
1933 * 195 1 Mixed European population 1969 White 1969 Japanese White White 1974 White, black, and Oriental 1980 White and black
‘information
not reported.
Table
Previous reports of interpupillary
Ill.
average (mm)
25.5-38.5 * * * * * 35 31.2
Group Population
Gunther3 Lucas and Pryor’ Waardenburg4 Pryor*
1933 1935 1951 1969
Feingold
1974
Mixed European populations White Mixed European populations Japanese Mexican White Mixed: black, white and Oriental
*Information
and Bossert5
MED
ORAL
PATHOL June 1990
SD (mm)
Male (mm)
SD fmml
Range(mm)
Female (mm)
* * * * * *
* 33-34 30 (25 pts.) 34.0 (66 pts.) 32.0 (186 pts.) 31.0 (512 pts.) *
* * 2.5 3.0 2.4 3.1 *
26.5-38.5 26-39 27-35 28-42 26-39 27-34 *
* 32-33 30 (25 pts.) 32.0 (83 pts.) 3 1 .o (205 pts.) 3 1 .O (496 pts.) *
2.5
31.7 (53 pts.)
2.8
26-38
30.8 (47 pts.)
distance
Date
Investigator
ORAL
distance Group
Investigator
SURF
average (mm) * * * * * * 63
SD (mm)
Male (mm)
SD (mm)
Range (mm)
Female (mm)
* * * * * * *
*
*
59 (119 pts.) 65.33 66.0 (66 pts.) 65.0 (31 pts.) 62.0 (186 pts.) *
5.2 *
59-11.5 52-65 58-75 59-75 59-68 58-75 *
* 59 (151 pts.) 62.67 64.0 (64 pts.) 64.0 (18 pts.) 60.0 (205 pts.) *
3.4 2.0 3.5 *
not reported
dromes, as well as allowing for earlier therapeutic and surgical intervention. l 2 Several soft-tissue variations in the medial canthal region may appear clinically as telecanthus, although the underlying median canthal ligament is intact. These include epicanthus, a vertical band of skin adjacent to the bridge of the nose overlying the median canthus, blepharophimosis, a general diminution of the palpebral aperture,12 and the mongolian fold. Soft tissue abnormalities resulting from underlying deformities of the orbital frame may also result in an illusory telecanthus. Included in this group are lateral osseous malformations or traumatic injuries causing obliqueness of the palpebral fissure, resulting in the mongoloid or antemongoloid slant. These entities may appear as a normal racial phenotype, an isolated entity, or a component of a syndrome. HYPERTELORISM
Orbital hypertelorism is an increase in distance between the osseous orbits, with an associated lateral _^^_. shift oi the median canthal soft lissileS ~tm&iiig iii the “secondary telecanthus” described by DeMyer.8 Visual diagnosis without measurement is often diffi-
cult because multiple ocular adnexal changes may create an illusory hypertelorism. Among these conditions are a flat nasal bridge, epicanthal folds, extreme strabismus, widely placed eyebrows, primary telecanthus, blepharophimosis, and narrow palpebra1 fissures.2, 8 True orbital hypertelorism is always a congenital defect. Trauma can produce telecanthus or disruption of the orbital frame, but traumainduced bilateral displacement of both orbital osseous frameworks would require a significant defect.13 Orbital hypertelorism does not appear as an isolated entity but occurs secondary to either a median facial dysraphia, an encephalocoele, a facial cleft, or a craniosynostosis.‘3 Clinical measurement for hypertelorism has been the subject of controversy. Many of the techniques are dependent on the measurement of intercanthal distance and are inaccurate in the presence of primary telecanthus or median canthal soft tissue anomalies. Thus in the abnormal person, in whom evaluation would be most valuable, these techniques are not of great value.* Interpupillary distance is traditionally used in the clinical assessment of the bony orbits because it is the most readily available anatomic marker,2 and this is a satisfactory mode of
Intercanthal and interpupillary
Volume 69 Number 6
-----+;
(mm)
* *
* *
3.0 2.6 2.4 3.0 *
25.5-36.5 24-31 25-33 25-42 24-31 26-33 *
IS+ 16-24 16-24 1s 14
2.2
27-36
42
_
A
* * 50 149 391 1006 *
Normal
Primary Telecanthus
B
100
#P-Y ,:
: _
Telecanthusplus \ TemporalDisplacement of Puncta
---.
Bl
SD
Imml * 4.4 * 3.4
1.8 3.4 *
Range (mn1l
4~e for) (mean)
No. of puiirnrs
58-70.5 43-64 54-72 55-74 62-69 54-72 *
*
*
*
270 *
16-24 15 16-24 14
130 49 391 *
15
679
Distance of pupil lo midline
,+‘7 ** *
SD
distance
evaluation with a cooperative patient; however, with the uncooperative patient, such as the newborn or a person with several anomalies, measurement is diffiCUk8 As an alternative, Tessier13 suggested evaluation with a posteroanterior radiograph taken at 4 m with the patient’s forehead and nose positioned against the film. The dacryon, a surgical and radiographic landmark located at the junction of the lacrimal, maxillary, and frontal bones, serves as the point of reference for the determination of the interorbital distance. This is not always an accurate measurement for the presence of hypertelorism, because the dacryon may bulge out from the median orbitai osseous structures beyond the lacrimal crests in conditions such as craniostenosis.‘3 However, this technique has an advantage in that it attempts to directly measure the distance between the orbits and does not depend on soft tissue parameters. Our study dealt with an adult population, which would limit its application in evaluation of the infant. Although it is known that the intercanthal distance attains 78% of the adult measurement at the age of 1 year,6 further investigations still need to be conducted in older children. In addition, the black
.,A..
C
\
Pure Hypertelorism
Fig. 1. Eyelid morphology, A, normal eyelids; B, primary telecanthus; C, pure hypertelotism. (From Puttermann AM, Pashayan H, Pruzansky S. Am J Opthalmol 1973;76:825-31.) (Published with permission from The American Journal of Ophthalmology. Copyright by the Ophthalmic Publishing Company.)
population is no more a homogeneous group than the white population; each has numerous subpopulations containing characteristic phenotypes. However, when this is taken into consideration, the data from this study still provide some guidance in the making of clinical determinations. REFERENCES
I L ae\tadius ND, 4asc JM. Srnlth DW. Normal 1 ?.
3
5.
inner canthal
and outer orbIta dimcnslons. J Pediatr 1979:74:465-8. Pryor HB. Objective measurement of interpupiliary distance. Pcdiatrizs i%9;43:973-7. Gunther H. tionstitutionelle ,lnomoiicn des augcnabstandesund der interorbital brcite. Virchows Arch [A] 1933: 290:373-x4. U’aardenburg PJ. A new syndrome combining developmental anomalies of the eyelids, eyebrows, and nose root with pigmentary defects of the iris and head hair with congenital deafness. Am J Hum Gcnet 1951;3:195-253. Feingold M. Bossert WH. Normal values for selected physical parameters: an aid to syndrome delineation. New York: The National Foundation/March of Dimes, vol 10. 1974:1-9.
6 Freihofer HPM. Inner intercanthal and interorbital distances. J Maxillofac Surg 1980;8:324-6. 7. Lucas WP, Pryor HB. Range and standard deviation of certain physical 1935:6:533-45.
measurements
in healthy
children.
J Pediatr
680
8. 9.
10.
11. 12.
Murphy
and Laskin
0~4~
DeMyer W. The median clef1 fact hyndrome. Neurolog! 1967;17:961-71. Mathog RH. Posttraumatic telecanthus. In: Mathog RH. cd. Maxillofaciai trauma. Baltimore: Williams & Wilkins. 1983:303-18. Furnas DW, Bircoll MJ. Eyelash traction test to detcrminc of the medial canthal ligament is detached. Plast Reconstr Surf 1973;52:315-7. Mustarde JC. Repair and reconstruction in the orbital region Edinburgh: Churchill Livingstone 1980: 167. Miller M. Pruzansky S. Craniofacial anomalies In, Penman GA, Sanders. DR. Goldberg MF, eds. Principles and practlcc
BOUND
VOLUMES
AVAILABLE
of ophthalmology, 2354-61. I?. Tessier P. Orbital 1972:6:135-55. Reprint
requests
Dr. Daniel M. Department of Medical College Box 566. MCV Richmond, VA
%I<(,
ORAL
vnl 3. Philadelphia: hypcrtelorism.
Stand
Mm
WB Saunders.
1980:
J Plast Reconstr
Surg
to:
L.askin Oral and Maxillofacial of Virginia Station 23298.0566
ORAL. P~THOL June 1990
Surgery
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distance in
DDS,a and Daniel M. Laskin, DDS, MS,h Richmond,
OF ORAL
AND
MAXILLOFACIAL
SURGERY,
MEDICAL
COLLEGE
Va, OF VIRGINIA
lntercanthal distance is an important measurement in the evaluation of congenital deformities and posttraumatic telecanthus. In this study 100 black patients (71 female and 29 male) were measured for intercanthal and interpupillary distance. For the overall group the mean intercanthal distance was 33.9 + 3.0 mm; previous studies of white persons and mixed populations indicate an average of 32 + 3 mm. The mean interpupillary distance for this study was 63.7 r 3.7 mm; previous studies indicate an average of 63 k 3 mm. This study suggests that the intercanthal and interpupillary distances in blacks are similar to findings of previous studies on whites and mixed populations.
(ORALSURGORALMEDORAL PATHOL1990;69:676-80)
I
ntercanthal distance is an important measurement in the evaluation of congential deformities and posttraumatic telecanthus. Previous studies have been performed on the white population’, 2; however, no studies have focused exclusively on the black population. The purpose of this study was to determine the intercanthal distance and the interpupillary distance for the black population and to determine whether differences exist between these data and those from previous studies on other populations. METHODS
One hundred black patients from the Medical College of Virginia (71 female and 29 male; mean age, 46 years) with no prior history of trauma or congenital anomaly were measured for intercanthal and interpupillary distance. Measurements were made with a Miltex caliper rule (Miltex Inc., Lake Success, N.Y.) to the nearest 0.5 mm. Intercanthal distance was measured between the median angles of the palpebral fissures, and interpupillary distance was measured between the midpoint of the pupils. RESULTS
For the overall group the mean intercanthal distance was 33.9 -t 3.0 mm (range, 28 to 43.5 mm) (Table I). The difference between men (35.7 f 3.7
7/12/10358 676
mm) and women (33.1 ? 2.3 mm) was statistically significant (p < 0.0001, unpaired t test). Mean interpupillary distance for the group was 63.7 f 3.7 mm (range, 55 to 73 mm) (Table I). The difference between men (66.3 +- 3.6 mm) and women 62.6 +3.2 mm) was statistically significant (p < 0.0001, unpaired t test). DISCUSSION
Intercanthal and interpupillary distances are integral measurements in the evaluation of facial trauma and may aid in the early identification and diagnosis of numerous congenital craniofacial syndromes. In addition, these measurements are essential in the treatment planning and surgical correction of congenital and posttraumatic deformities. Several previous studies have been conducted on white and racially mixed groups of varying ages;however, none have focused exclusively on the black population. This study found the intercanthal and interpupillary distance of the black population to be similar to that reported in previous studies of white and mixed populations (Tables II and III). Gunther3 found the normal intercanthal distance in whites to range between 25.5 and 38.5 mm. Studying a mixed European population, Waardenburg4 found the intercanthal distance to average 33 to 34 mm in the male and 32 to 33 mm in the female. In the adult population portion of their study, Laestadius et al.’ found the distance to measure 30 + 2.5 mm in males and 30 -t 3.0 mm in female. In a study of mixed
Intercanthal
Volume Number
69 6
Table
I. Mean intercanthal GOUp
lntercanthal Combined Male Female Interpupillary Combined Male Female /CD,
lntercanthal
and interpupillary __-__ ICDor IPD
100 29
33.9 35.7
0.302 0.68 1
3.0 3.1
71
33.1
0.279
2.3
100
63.7
0.368
3.1
29 71
66.3 62.6
0.67 1 0.374
3.6 3.2
.--__~-d~!&nce,
[PD.
intcrpupillnry
distance
677
distance in the black population
No. of patients
(mm)
and interpupillary
SE (mm)
SD (mm) -----
~- -;zz%~
0.000
0.0001
-_--
1
28-43.5
55-73
__.-~-
distance.
populations, Feingold and Bossert’ found the overall intercanthal distance to be 35 mm. Freihofer6 found an average intercanthal distance of 31.2 + 2.5 mm, with no statistical difference between the sexes. According to the accumulated data from the previous studies, the average intercanthal distance is approximately 32 mm, with an SD of 3 mm. The results from our study of the black population fall within this range, although the figures, especially for males, appear to be slightly greater than those reported in some studies. Lucas and Pryor found the average interpupillary distance to be 59 mm (male SD + 4.4; female SD * 5.2). Studying a mixed European population, Waardenberg4 found the interpupillary distance to average 65.3 mm for males and 62.7 mm for females. Feingold and Bossert5 found the overall average to be 63 mm and, in studies of Japanese, Mexican, and white groups, Pryor found the average to range between 60 and 65 mm. The average interpupillary distance from these studies is approximately 63 mm, with an SD of 3 mm. The results of our study on the black population also fall within this range. TELECANTHUS
The intercanthal distance is of primary importance in the evaluation of facial trauma and congenital deformities. This distance is maintained by the median canthal ligament, which connects the tarsal plates and palpebral structures to the median orbital structures. Telecanthus is an increase in the distance between the median canthi. DeMyers differentiates between primary and secondary telecanthus. Primary telecanthus is caused by an increase in soft tissue with a normal interpupillary and interbony distance; secondary telecanthus is the result of an increase in interpupillary and interbony distance, as is found in hypertelorism, with subsequent widening of the soft
tissue intercanthal distance (Fig. 1). Primary telecanthus is often a result of trauma. Disruption of the median canthal ligament involves either detachment of the bone anchoring the ligament or transection of the ligament and can be associated with direct trauma to the nasoethmoidal structures or Le Fort II or Le Fort III fractures. Posttraumatic telecanthus is reported to occur in 12% to 20% of all midface fractures9 Forces from the orbicularis oculi and levator palpebrae muscles pull the unsecured ligament anteriorly and laterally, resulting in the characteristic rounding of the median canthal soft tissues and shortening of the horizontal palpebral fissure.2, t l Epiphora results from either detachment of Horner’s muscle, with subsequent failure of the puncta to approximate the globe, or direct injury or kinking of the nasolacrimal apparatus. In addition, detachment of Horner’s muscle results in laxity of the eyelids, with increased visibility of the sclera.9 Evaluation of traumatized patients for telecanthus involves measurements and comparisons with known norms for the region. If assessment is difficult because of tissue damage or posttraumatic edema, continuity of the median canthal ligament can be tested by placing lateral traction on the upper eyelid; this tension is transmitted through the tarsal plates to the ligament, which can then be visualized or palpated.‘e In the absence of trauma, evaluation of the intercanthal distance should take into account common variations in median canthal soft-tissue anatomy, as well as congenital deformities occurring as isolated entities or components of various syndromes. Examination of the characteristics of the intercanthal and ocular adnexa is important in the identification of numerous craniofacial anomalies. Proper diagnosis can aid the clinician in anticipating late-appearing associated defects, such as the progressive exophthalmos associated with Apert’s and Crouzon’s syn-
678
Murphy
and Laskin
Table
Ii. Previous reports of intercanthal -.~
ORAL
Gunther3 Waardenburg4 Laestadius et al.’ Pryor’
Feingold Freihofer6
and Bossert5
Date
Population
1933 * 195 1 Mixed European population 1969 White 1969 Japanese White White 1974 White, black, and Oriental 1980 White and black
‘information
not reported.
Table
Previous reports of interpupillary
Ill.
average (mm)
25.5-38.5 * * * * * 35 31.2
Group Population
Gunther3 Lucas and Pryor’ Waardenburg4 Pryor*
1933 1935 1951 1969
Feingold
1974
Mixed European populations White Mixed European populations Japanese Mexican White Mixed: black, white and Oriental
*Information
and Bossert5
MED
ORAL
PATHOL June 1990
SD (mm)
Male (mm)
SD fmml
Range(mm)
Female (mm)
* * * * * *
* 33-34 30 (25 pts.) 34.0 (66 pts.) 32.0 (186 pts.) 31.0 (512 pts.) *
* * 2.5 3.0 2.4 3.1 *
26.5-38.5 26-39 27-35 28-42 26-39 27-34 *
* 32-33 30 (25 pts.) 32.0 (83 pts.) 3 1 .o (205 pts.) 3 1 .O (496 pts.) *
2.5
31.7 (53 pts.)
2.8
26-38
30.8 (47 pts.)
distance
Date
Investigator
ORAL
distance Group
Investigator
SURF
average (mm) * * * * * * 63
SD (mm)
Male (mm)
SD (mm)
Range (mm)
Female (mm)
* * * * * * *
*
*
59 (119 pts.) 65.33 66.0 (66 pts.) 65.0 (31 pts.) 62.0 (186 pts.) *
5.2 *
59-11.5 52-65 58-75 59-75 59-68 58-75 *
* 59 (151 pts.) 62.67 64.0 (64 pts.) 64.0 (18 pts.) 60.0 (205 pts.) *
3.4 2.0 3.5 *
not reported
dromes, as well as allowing for earlier therapeutic and surgical intervention. l 2 Several soft-tissue variations in the medial canthal region may appear clinically as telecanthus, although the underlying median canthal ligament is intact. These include epicanthus, a vertical band of skin adjacent to the bridge of the nose overlying the median canthus, blepharophimosis, a general diminution of the palpebral aperture,12 and the mongolian fold. Soft tissue abnormalities resulting from underlying deformities of the orbital frame may also result in an illusory telecanthus. Included in this group are lateral osseous malformations or traumatic injuries causing obliqueness of the palpebral fissure, resulting in the mongoloid or antemongoloid slant. These entities may appear as a normal racial phenotype, an isolated entity, or a component of a syndrome. HYPERTELORISM
Orbital hypertelorism is an increase in distance between the osseous orbits, with an associated lateral _^^_. shift oi the median canthal soft lissileS ~tm&iiig iii the “secondary telecanthus” described by DeMyer.8 Visual diagnosis without measurement is often diffi-
cult because multiple ocular adnexal changes may create an illusory hypertelorism. Among these conditions are a flat nasal bridge, epicanthal folds, extreme strabismus, widely placed eyebrows, primary telecanthus, blepharophimosis, and narrow palpebra1 fissures.2, 8 True orbital hypertelorism is always a congenital defect. Trauma can produce telecanthus or disruption of the orbital frame, but traumainduced bilateral displacement of both orbital osseous frameworks would require a significant defect.13 Orbital hypertelorism does not appear as an isolated entity but occurs secondary to either a median facial dysraphia, an encephalocoele, a facial cleft, or a craniosynostosis.‘3 Clinical measurement for hypertelorism has been the subject of controversy. Many of the techniques are dependent on the measurement of intercanthal distance and are inaccurate in the presence of primary telecanthus or median canthal soft tissue anomalies. Thus in the abnormal person, in whom evaluation would be most valuable, these techniques are not of great value.* Interpupillary distance is traditionally used in the clinical assessment of the bony orbits because it is the most readily available anatomic marker,2 and this is a satisfactory mode of
Intercanthal and interpupillary
Volume 69 Number 6
-----+;
(mm)
* *
* *
3.0 2.6 2.4 3.0 *
25.5-36.5 24-31 25-33 25-42 24-31 26-33 *
IS+ 16-24 16-24 1s 14
2.2
27-36
42
_
A
* * 50 149 391 1006 *
Normal
Primary Telecanthus
B
100
#P-Y ,:
: _
Telecanthusplus \ TemporalDisplacement of Puncta
---.
Bl
SD
Imml * 4.4 * 3.4
1.8 3.4 *
Range (mn1l
4~e for) (mean)
No. of puiirnrs
58-70.5 43-64 54-72 55-74 62-69 54-72 *
*
*
*
270 *
16-24 15 16-24 14
130 49 391 *
15
679
Distance of pupil lo midline
,+‘7 ** *
SD
distance
evaluation with a cooperative patient; however, with the uncooperative patient, such as the newborn or a person with several anomalies, measurement is diffiCUk8 As an alternative, Tessier13 suggested evaluation with a posteroanterior radiograph taken at 4 m with the patient’s forehead and nose positioned against the film. The dacryon, a surgical and radiographic landmark located at the junction of the lacrimal, maxillary, and frontal bones, serves as the point of reference for the determination of the interorbital distance. This is not always an accurate measurement for the presence of hypertelorism, because the dacryon may bulge out from the median orbitai osseous structures beyond the lacrimal crests in conditions such as craniostenosis.‘3 However, this technique has an advantage in that it attempts to directly measure the distance between the orbits and does not depend on soft tissue parameters. Our study dealt with an adult population, which would limit its application in evaluation of the infant. Although it is known that the intercanthal distance attains 78% of the adult measurement at the age of 1 year,6 further investigations still need to be conducted in older children. In addition, the black
.,A..
C
\
Pure Hypertelorism
Fig. 1. Eyelid morphology, A, normal eyelids; B, primary telecanthus; C, pure hypertelotism. (From Puttermann AM, Pashayan H, Pruzansky S. Am J Opthalmol 1973;76:825-31.) (Published with permission from The American Journal of Ophthalmology. Copyright by the Ophthalmic Publishing Company.)
population is no more a homogeneous group than the white population; each has numerous subpopulations containing characteristic phenotypes. However, when this is taken into consideration, the data from this study still provide some guidance in the making of clinical determinations. REFERENCES
I L ae\tadius ND, 4asc JM. Srnlth DW. Normal 1 ?.
3
5.
inner canthal
and outer orbIta dimcnslons. J Pediatr 1979:74:465-8. Pryor HB. Objective measurement of interpupiliary distance. Pcdiatrizs i%9;43:973-7. Gunther H. tionstitutionelle ,lnomoiicn des augcnabstandesund der interorbital brcite. Virchows Arch [A] 1933: 290:373-x4. U’aardenburg PJ. A new syndrome combining developmental anomalies of the eyelids, eyebrows, and nose root with pigmentary defects of the iris and head hair with congenital deafness. Am J Hum Gcnet 1951;3:195-253. Feingold M. Bossert WH. Normal values for selected physical parameters: an aid to syndrome delineation. New York: The National Foundation/March of Dimes, vol 10. 1974:1-9.
6 Freihofer HPM. Inner intercanthal and interorbital distances. J Maxillofac Surg 1980;8:324-6. 7. Lucas WP, Pryor HB. Range and standard deviation of certain physical 1935:6:533-45.
measurements
in healthy
children.
J Pediatr
680
8. 9.
10.
11. 12.
Murphy
and Laskin
0~4~
DeMyer W. The median clef1 fact hyndrome. Neurolog! 1967;17:961-71. Mathog RH. Posttraumatic telecanthus. In: Mathog RH. cd. Maxillofaciai trauma. Baltimore: Williams & Wilkins. 1983:303-18. Furnas DW, Bircoll MJ. Eyelash traction test to detcrminc of the medial canthal ligament is detached. Plast Reconstr Surf 1973;52:315-7. Mustarde JC. Repair and reconstruction in the orbital region Edinburgh: Churchill Livingstone 1980: 167. Miller M. Pruzansky S. Craniofacial anomalies In, Penman GA, Sanders. DR. Goldberg MF, eds. Principles and practlcc
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%I<(,
ORAL
vnl 3. Philadelphia: hypcrtelorism.
Stand
Mm
WB Saunders.
1980:
J Plast Reconstr
Surg
to:
L.askin Oral and Maxillofacial of Virginia Station 23298.0566
ORAL. P~THOL June 1990
Surgery
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