Refractive Changes in Epiblepharon
PASSORN PREECHAWAI, SHANTHA AMRITH, INEZ WONG, AND GANGADHARA SUNDAR
PURPOSE: To study the prevalence of astigmatism in
patients with epiblepharon and keratopathy and to deter-
mine if astigmatism was influenced by surgical correc-
tion.
DESIGN: This is a retrospective review of 182 eyes of
91 patients who were diagnosed with significant
epiblepharon at the National University Hospital, Singa-
pore.
METHODS: Demographic data, best-corrected visual
acuity, refractive error at presentation and annually
thereafter, presence of amblyopia, severity of keratopa-
thy, and nature of surgical intervention if any were
recorded.
RESULTS: Mean age of the patients was 7.23 6.43
years. 52.2% of patients had astigmatism of 1 diopter (D)
or more (range, 0.5 to 4.0 D), and the astigmatism
was largely with-the-rule. There was no significant
association between severity of keratopathy and astigma-
tism. Nine percent of patients had amblyopia after specta-
cle correction and all had significant astigmatism. A total
of 70.3% of patients underwent surgery and mean time
to surgery was 12.2 13.1 months after diagnosis. Mean
age to surgery was 7.5 7.12 years. Comparison of pre-
and postoperative astigmatism in patients younger than
age 5 at the time of surgery showed no significant changes
in astigmatism at one to two years of follow-up.
CONCLUSIONS: There was high prevalence of astigma-
tism in patients with epiblepharon (52.2% had 1 D or
more of astigmatism). A total of 9% of patients had
amblyopia from astigmatism. Surgery did not seem to
affect astigmatism especially in young children. Possibil-
ity of amblyopia from astigmatism must be borne in mind
while treating children with epiblepharon. (Am J Oph-
thalmol 2007;143:835 839. 2007 by Elsevier Inc.
All rights reserved.)
E
PIBLEPHARON IS A COMMON CONDITION AMONG
Asian children. A fold of skin and pretarsal orbicu-
laris override the lid margin causing the eyelashes to
turn inwards in some patients, causing keratopathy. The
etiology of this disease may be manifold. The pretarsal
orbicularis muscle and skin are weakly attached to the
Accepted for publication Jan 24, 2007.
From the Department of Ophthalmology, Faculty of Medicine, Prince
of Songkla University, Had Yai, Songkhla, Thailand (P.P.); Department
of Ophthalmology, National University Hospital, 5 Lower Kent Ridge
Road, Singapore (P.P., S.A., I.W., G.S.).
Inquiries to Shantha Amrith, Senior Consultant, Head of Oculoplastic
Service, Department of Ophthalmology, National University Hospital, 5,
Lower Kent Ridge Rd., Singapore 119074; e-mail: shantha@nuheye.com
0002-9394/07/$32.00 2007 BY ELSEVIER INC. ALL
doi:10.1016/j.ajo.2007.01.043
tarsus below, thus raising a skin fold near the lid margin
and thus pushing the eyelashes toward the cornea1,2
(Figure 1). Other possible causes are the failure of the
upper or the lower lid retractor to gain access to the skin,
failure of interdigitation of septae in subcutaneous plane,
and hypertrophy of orbicularis muscle. The severity of the
horizontal fold of skin and consequent number of inverted
eyelashes in epiblepharon is variable, thus affecting the
severity of symptoms. Prolonged corneal irritation from
eyelashes or aggressive rubbing of the eyes may produce
keratopathy as well as corneal astigmatism and therefore
the risk of amblyopia. From our observations, we noted
that a significant number of patients with epiblepharon
had refractive errors and among them, a small proportion
had amblyopia. The aims of our study were: 1) to investi-
gate the prevalence of astigmatism in patients with
epiblepharon, 2) its relationship to severity of keratopathy,
and 3) to determine if the astigmatism changed after surgical
correction, especially in children younger than age 5.
METHODS
WE RETROSPECTIVELY REVIEWED 182 EYES OF 91 PATIENTS
who had been diagnosed with epiblepharon of the lower or
upper lids at the National University Hospital, Singapore
between 2000 and 2005 after obtaining approval from the
domain specific review board of our institution. The patients
were selected from the oculoplastic clinic and the main
selection criterion included the presence of lash-corneal
touch from epiblepharon either in primary position and or
in down or up gaze. Demographic data, which included age
and gender of the patients, the best-corrected Snellens visual
acuity, refractive errors by cycloplegic refraction in patients
younger than age 7 and noncycloplegic manifest refraction in
patients older than age 7, were noted. All patients were
managed conservatively with lubricant eye drops and oint-
ment for a period as evidenced by the meantime to surgery.
Surgical correction was offered only to patients with unre-
solving keratopathy and persistent symptoms.
Surgical procedure (Hotz procedure) consisted of re-
moval of the excess skin and muscle with fixation sutures
to tarsal plate (Figure 2) thereby creating a crease to
prevent the overriding of the pretarsal muscle on to the lid
margin. In some patients, four to five evenly placed
everting sutures with 4/0 Vicryl were applied along the
whole length of the eyelid to achieve the same effect. In
patients who had surgery for the correction of epiblepha-
ron, the age at which the surgical correction was performed
RIGHTS RESERVED. 835
FIGURE 1. Diagramatic illustration of lower lid epiblepharon. Note the high attachment of the orbital septum with fat intervening
between tarsal plate and orbicularis. This prevents connective tissue adhesion to capsulopalpebral fascia and migration of pretarsal
orbicularis raising a skin fold over the lid margin.

and the postoperative refraction done annually thereafter

were recorded. Amblyopia, if any, and treatment results
were noted. Amblyopia was deemed to be present if there
was a difference of 2 Snellen lines between the best-
corrected visual acuities of the two eyes or if the best-
corrected visual acuity was equal to or less than 20/60 in
both the eyes. Severity of keratopathy, categorized into
three groups as mild (less than 10 punctate epithelial
erosions staining with fluorescein), moderate (more than
10 punctate epithelial erosions in the cornea), and severe
[Figure 3] (confluent punctate epithelial erosions or opac-
ity or vascularization of the cornea), was recorded.

FIGURE 2. Surgical procedure (Hotz procedure) for epiblepha-

ron correction. Note 6/0 Vicryl sutures evenly placed to fixate RESULTS
skin to tarsal plate after excision of overriding skin and
orbicularis. ONE HUNDRED AND EIGHTY-TWO EYES OF 91 PATIENTS
were reviewed. Forty-eight (52%) were male and 43 (48%)

836 AMERICAN JOURNAL OF OPHTHALMOLOGY MAY 2007


FIGURE 3. Severe keratopathy in a case of epiblepharon of
lower eyelids with lash corneal touch. Note the confluent
staining with fluorescein.
FIGURE 4. The number of cases of epiblepharon with astig-
matism of >1.00 diopter (D) in patients with different degrees
of keratopathy.
were female. Four of the 91 patients had significant
epiblepharon in all four eyelids and one patient had
epiblepharon of the upper lids alone. Remaining 86 pa-
tients had epiblepharon of the lower lids only. All but one
were of Chinese ethnicity. The only non-Chinese patient
was ethnically Malay. The mean age was 7.23 6.43 years
(range, six months to 30 years), of whom the majority were
younger than 6 years old, as evidenced by the median age,
which was 5. There were seven patients older than age 18.
The epiblepharon seen in older patients had been present
since early childhood, indicating that they were all devel-
opmental in nature. Keratopathy was seen in the upper or
lower half of the cornea with a slight predilection for nasal
quadrants depending on whether it was upper or lower
epiblepharon and it was always proportional to the number
and thickness of the eye lashes rubbing on the cornea. The
degree of keratopathy was mild in 35 (39.2%), moderate in
32 (34.8%), and severe in 24 (26.0%) of those patients.
The best-corrected visual acuity of 20/40 was found in 75
VOL. 143, NO. 5 REFRACTIVE CHANGES
(82.7%) patients, between 20/50 to 20/120 in 15 patients
(16.8%), and 20/200 in one (0.5%) patient. The refrac-
tion showed a mean spherical error of 0.21 3.35 D for
the right eye and 0.25 3.43 D for the left eye at the first
visit. The prevalence of astigmatism of 1 D or more was
found in 95 of the 182 (52.2%) eyes, largely with the rule
(86 eyes or 90.5%) and only in nine eyes (9.5%) the
astigmatism was oblique. Mean astigmatism for the right
eye was 1.58 1.08 D (0.00 to 4.00 D) and the left
eye was 1.57 1.22 D (0.00 to 4.00 D). Figure 4
shows the prevalence of astigmatism of 1 D in patients
with different degrees of keratopathy. Using analysis of
variance we found no significant association between the
severity of astigmatism and severity of keratopathy.
Amblyopia was present in nine of the 91 (9.9%)
patients after fully correcting the refractive error. Three
patients had unilateral amblyopia attributable to a higher
astigmatism in that eye. Six patients had best-corrected
visual acuity of 20/60 and 20/80 from meridional amblyo-
pia. All the unilateral cases with higher astigmatism in the
amblyopic eye improved with patching. All the bilateral
cases improved without patching after using spectacle
correction for a few months.
Sixty-four patients (70.3%) underwent surgery and the
meantime to surgery after the diagnosis was 12.2 13.1
months and mean age was 7.5 7.12 years. Twelve
patients (18.8%) had suture correction and the remaining
patients underwent Hotz procedure. There were nine
recurrences, of which five had repeat surgery (Hotz proce-
dure). Keratopathy resolved in all patients after surgical
correction. Of the 64 patients who underwent surgery, 25
were younger than age 5. A total of 42% (21 eyes of 50)
had significant astigmatism. The mean preoperative astig-
matism in those children of the right and left eyes were
1.39 1.01 D and 1.14 0.83 D, respectively, and
one to two years after surgery, the mean astigmatisms were
1.75 1.27 D and 1.55 0.91 D. No significant shifts
in the axes were noted. We compared astigmatism before
and after surgery in children younger than age 5 and found
that there was no significant change in the astigmatism
(Chi-square test) at one to two years of follow-up.
DISCUSSION
A LARGE PROPORTION OF ASIAN CHILDREN ARE SYMPTOM-
atic from the presence of epiblepharon. Because epiblepha-
ron may resolve without treatment as facial development
expands the nasal bridge and mid-face, all our patients
were observed with conservative management as evi-
denced by the meantime to surgery, which is 12.2 13.1
months. The cause of epiblepharon is controversial.2 6
Some believe that it may be a combination of hypertro-
phied muscle with an extra skin fold. The pathogenesis of
the abnormal fold may be a relative hypoplasia of the nasal
bridge or an absence of the connective tissue between the
IN EPIBLEPHARON 837
capsulopalpebral fascia and the skin, allowing preseptal
orbicularis to override pretarsal orbicularis muscle.7 In
Asian eyelids, the orbital septum is attached higher on the
tarsal plate in the lower eyelid (Figure 1), and lower in the
upper eyelid, thereby preventing the connective tissue
attachments to deeper tissues.
The incidence and prevalence of astigmatism of 1 D in
Singapore children between seven and nine years of age
was reported in two separate studies as 11.5%8 and 19%.9
Children with epiblepharon were not eliminated in those
studies. The first study8 revealed the incidence of astigma-
tism to be significantly higher (P value of .001) in
Chinese children (13.9%) as compared with the non-
Chinese (4.5%). Ethnicity and myopia were identified as
risk factors for astigmatism. In the second study,9 the range
of astigmatism was found to be between 0.00 and 3.75 D,
and 82.5% of children had with-the-rule astigmatism. Our
study showed that the prevalence of astigmatism in chil-
dren with significant epiblepharon was higher than what
was reported in Singapore school children, although the
range and astigmatic axis were similar.
The prevalence of epiblepharon in infants aged one or
less in Japan was 25% to 27%.10,11 Yang and associates
reported an association with astigmatism of more than 1 D
in 50.9%12 and astigmatism of more than 0.5 D in 70.3%
of the cohort. Another study found 35% having anastig-
matism over 1 D13 and 54% over 0.5 D. Both studies
reported that most were with-the-rule astigmatism.12,13
Our results are very similar to those of Yang and associates,12
52% having an astigmatism of 1 D or more and more than
90% with-the-rule. Furthermore, Khwarg13 found that the
greater the corneal injury or the higher the number of cilia
touching the cornea, the more severe was the astigmatism. In
our study, we failed to find that correlation possibly because of
the small number of patients in each subgroup.
Many authors hypothesized the mechanism of astigma-
tism in epiblepharon in children. It was postulated that the
high degree of astigmatism/keratoconus is induced in
allergic patients with the positive history of eye rub-
bing.13,14 The evidence for the theory is only circumstan-
tial. It has been shown that in patients with congenital
ptosis, the corneal curvature is altered because of the ptotic
eyelid.15,16 Ben Simon and associates17 reported a case of
astigmatism that was induced by reverse ptosis of the lower
THE AUTHORS INDICATE NO FINANCIAL SUPPORT OR FINANCIAL CONFLICT OF INTEREST. INVOLVED IN DESIGN AND
conduct of study: (P.P., S.A., I.W., G.S.); collection: (P.P., I.W.); management: (S.A., G.S.); analysis and interpretation of data, statistician, and
preparation: (P.P., S.A.); and review and approval of manuscript (P.P., S.A., I.W., G.S.).
The authors would like to thank Y. H. Chan Yiong Huat, PhD, the Head of Biostatistics Department, National University of Singapore, for his
valuable guidance and help in the data analysis.
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838 AMERICAN JOURNAL
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reverse ptosis. This report indicated that it is not just the
upper eyelid, but also the lower eyelid, which can influence
the corneal curvature. We believe that the astigmatism in
epiblepharon may partly be the result of the changes in the
corneal curvature induced by the pressure exerted by the
abnormal horizontal skin fold that is constantly changing
from the dynamic movement of the eyelid.
If it were true that corneal irritation from lash-corneal
touch made patients squeeze or rub their eyes thereby
inducing astigmatism, surgery could possibly reduce the
corneal astigmatism, especially in younger patients. Our
results showed that there was no statistically significant
change in the astigmatism after surgery especially in the
group consisting of children younger than age 5, whose
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depending on whether the epiblepharon is in the upper or
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IN EPIBLEPHARON 839
 Biosketch
Passorn Preechawai, MD, Graduated from the medical school of Prince of Songkla University, Thailand in 1997 and
underwent residency training from Chaing Mai University, Thailand. Served as an international fellow in oculoplastic
surgery at the New York Eye and Ear Infirmary, observed at Bascom Palmer Eye Institute, USA in 2004 to 2005; and then
served as a clinical fellow in oculoplastic surgery at the National University Hospital, Singapore in 2005 to 2006.
Dr Preechawai is now working as a consultant at the Department of Ophthalmology, Prince of Songkla University,
Thailand.

839.e1 AMERICAN JOURNAL OF OPHTHALMOLOGY MAY 2007