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Original Investigation |

Association Between Head Tilt and Asymmetric Epiblepharon

Bo Ram Seol, MD1; Ho-Kyung Choung, MD2; Namju Kim, MD3; Min Joung Lee, MD4; Sang In Khwarg, MD1
[+] Author Affiliations
1Department of Ophthalmology, Seoul National University Hospital, Seoul, Korea
2Department of Ophthalmology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
3Department of Ophthalmology, Seoul National University Bundang Hospital, Seongnam, Korea
4Department of Ophthalmology, Hallym University Sacred Heart Hospital, Anyang, Korea
JAMA Ophthalmol. 2016;134(8):870-872. doi:10.1001/jamaophthalmol.2016.1375.
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Importance  Epiblepharon is known to be bilateral and symmetric. However, asymmetric epiblepharon is frequently observed in patients with head tilt and, to date, this condition has not been investigated.

Objectives  To evaluate the clinical features of epiblepharon in patients with head tilt and to analyze the association between the direction of head tilt and epiblepharon asymmetry.

Design, Setting, and Participants  The medical records of 1074 Korean children who received a diagnosis of epiblepharon between January 1, 2006, and October 31, 2013, at Seoul National University Bundang Hospital were retrospectively reviewed. The data collected included sex, age, extent and asymmetric presentation of epiblepharon, and direction and cause of head tilt.

Main Outcomes and Measures  The presence of epiblepharon asymmetry in patients with head tilt as well as the association between the direction of head tilt and the side having more severe epiblepharon.

Results  Of 1074 patients (536 boys; mean [SD] age, 5.4 [2.6] years) with epiblepharon, 38 individuals (3.5%) showed head tilt. The causes of head tilt were superior oblique palsy (18 patients [47.4%]), congenital muscular torticollis (10 [26.3%]), dissociated vertical deviation (3 [7.9%]), and unknown (7 [18.4%]). Asymmetric epiblepharon was more common in children with vs without head tilt (34 [89.5%] vs 80 [7.7%]; P < .001, Fisher exact test). Of the 34 patients with head tilt and asymmetric epiblepharon, the direction of head tilt was consistent with the side having more severe epiblepharon in 29 individuals (85.3%) and inconsistent in 5 individuals (14.7%) (P = .009).

Conclusions and Relevance  These data suggest that, in patients with epiblepharon and head tilt, epiblepharon is most often asymmetric and is severe in the head-tilted side. These results suggest that patients with asymmetric epiblepharon should be evaluated for head tilt.

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Figure 1.
Asymmetric Epiblepharon

Asymmetric epiblepharon was diagnosed when the difference of the extent of epiblepharon was more than one-fourth of the eyelid length. In the right eye, epiblepharon was found to involve less than one-fourth of the medial eyelid; however, in the left eye, the medial half of the eyelid was involved.

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Figure 2.
Asymmetric Unilateral Epiblepharon in a Patient With Head Tilt

A, Head tilt to the right side in a girl. B, On slitlamp examination, epiblepharon was found to be asymmetric, with greater severity in the head-tilted right side.

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