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Telecanthus

Telecanthus is a craniofacial anomaly characterized by an increased distance between the medial canthi of the eyes, with normal interpupillary distance and medial orbital wall positioning.^[1] This condition, also known as dystopia canthorum, results from lateral displacement or elongation of the medial canthal tendons rather than orbital widening, distinguishing it from hypertelorism.^[2]^[3] The normal adult inner canthal distance measures approximately 30–31 mm, and telecanthus is objectively diagnosed when this exceeds 2 standard deviations above the population mean, though ethnic variations exist in normative values.^[4] Telecanthus most often manifests as a congenital feature of genetic syndromes, including blepharophimosis, ptosis, and epicanthus inversus syndrome (BPES); Waardenburg syndrome; Down syndrome; Cornelia de Lange syndrome; and Axenfeld-Rieger syndrome.^[1]^[3] Acquired forms can arise from trauma, such as naso-orbital-ethmoidal fractures that disrupt the medial canthal tendon attachments, or from surgical interventions like tumor excisions (e.g., basal or squamous cell carcinomas) near the medial canthus.^[5]^[4] It is typically asymptomatic, causing no pain or direct impairment to vision, but may contribute to cosmetic concerns or affect self-esteem, particularly in children, and often co-occurs with other ocular dysmorphologies like epicanthal folds or ptosis.^[5] Diagnosis relies on precise measurement of the inner canthal distance using a ruler or caliper during clinical examination, supplemented by imaging such as CT scans to assess orbital structures and exclude underlying fractures or syndromes.^[5]^[4] Management is conservative if mild and isolated, but surgical correction—via medial canthopexy, tendon shortening, or transnasal wiring—is indicated for moderate to severe cases to improve aesthetics and function, with procedures ideally performed after skeletal maturity.^[5]^[4] Genetic counseling is recommended when syndromic associations are suspected to evaluate familial risks.^[1]

Definition and Terminology

Definition

Telecanthus is defined as a palpebral anomaly characterized by an increased distance between the medial canthi, the inner corners of the eyelids, while the interpupillary distance remains within normal limits.^[4]^[6] The interpupillary distance, measured between the centers of the pupils, is typically 60-62 mm in adults.^[7] This condition arises without altering the overall bony orbital structure or the distance between the pupils, distinguishing it as a soft tissue abnormality rather than a skeletal one. The normal inner intercanthal distance (ICD), measured between the medial canthi, is approximately 30-35 mm in adults, with slight variations by age, sex, and ethnicity.^[8] In neonates, the ICD is approximately 20 mm, increasing to 27-30 mm by early childhood (ages 2-4 years) and further to adult levels by adolescence.^[9]^[10] Anatomically, telecanthus involves an abnormal insertion or elongation of the medial canthal tendon, which normally anchors the eyelids to the anterior and posterior lacrimal crests on the lacrimal bone, thereby increasing the spacing without widening the orbital cavity.^[4]^[11] Telecanthus must be differentiated from hypertelorism, also known as orbital hypertelorism, where the increased medial canthal distance accompanies a broader interorbital bony distance and enlarged interpupillary distance due to actual separation of the orbits.^[3]^[12] In telecanthus, only the medial canthal spacing is affected, preserving normal orbital width and interpupillary alignment.^[13] The condition can be classified as congenital, present at birth due to developmental anomalies of the tendon, or acquired, resulting from trauma or other insults; it may also occur unilaterally or bilaterally.^[6]^[14]

Etymology

The term telecanthus is derived from the Greek prefix tele-, meaning "far" or "distant," combined with kanthos, denoting the corner of the eyelid, to describe an increased separation between the medial canthi. The root kanthos itself originates from Ancient Greek, referring specifically to the angle formed by the meeting of the upper and lower eyelids, and was adopted into Latin as canthus before entering medical nomenclature.^[15] An alternative term, dystopia canthorum, refers to the same condition and stems from the Greek elements dys-, meaning "bad" or "abnormal," topos for "place" or "position," and canthorum, the genitive form of canthus adapted to Latin morphology, emphasizing the malposition of the eyelid corners.^[16] This nomenclature highlights the lateral displacement of the medial canthi without necessarily altering the interorbital distance.^[16] The term telecanthus was introduced into medical literature by plastic surgeon John C. Mustardé in 1963 to distinguish it from orbital hypertelorism, focusing on the palpebral rather than bony separation. Earlier descriptions of related features appeared in the context of Waardenburg syndrome, where dystopia canthorum was formalized by Petrus J. Waardenburg in 1951 as a hallmark sign involving lateral shifting of the medial canthi.^[16] A related concept, pseudotelecanthus, describes an apparent increase in medial canthal distance that mimics true telecanthus but results from soft tissue changes such as swelling, scarring, or epicanthal folds overlying a flat nasal bridge, without actual bony or tendinous displacement.^[17]

Causes and Pathophysiology

Pathophysiology

Telecanthus results from abnormalities in the medial canthal tendon (MCT), a structure composed of anterior and posterior limbs that anchor the medial aspects of the eyelids to the anterior lacrimal crest of the lacrimal bone and the posterior lacrimal crest on the medial orbital wall, respectively. These abnormalities include improper insertion, elongation, or laxity of the MCT, which permit lateral displacement of the medial canthi and thereby increase the intercanthal distance while preserving a normal interpupillary distance.^[6]^[4] In congenital telecanthus, the condition arises from disrupted craniofacial development during the embryonic period, specifically a failure in the fusion of the frontonasal processes between the 4th and 8th weeks of gestation. This developmental arrest can lead to midline facial anomalies that affect the positioning or integrity of the MCT without necessarily altering the overall orbital architecture.^[3] Traumatically induced telecanthus occurs through disruption of the naso-orbital-ethmoidal (NOE) complex, typically from high-energy blunt force to the midface, resulting in avulsion, laceration, or bony detachment of the MCT from its lacrimal crest attachments, or displacement of the central NOE fragment. This leads to lateral displacement of the medial canthi due to MCT injury, increasing the intercanthal distance, though severe fractures may involve some splaying of the medial orbital walls without expansion of the orbital cavities themselves.^[18]^[4] The physiological consequences of telecanthus are primarily cosmetic but can include epiphora (excessive tearing) in severe cases, particularly when the disruption involves the adjacent lacrimal drainage system, such as the canaliculi or nasolacrimal duct, impairing tear outflow.^[11]

Etiology

Telecanthus arises from a variety of etiologies, primarily categorized as genetic, congenital non-genetic, or acquired. Genetic causes involve mutations in genes critical to craniofacial development, leading to syndromic presentations where telecanthus is a prominent feature.^[4] Among genetic etiologies, mutations in the PAX3 gene are associated with Waardenburg syndrome, characterized by dystopia canthorum or telecanthus alongside sensorineural hearing loss and pigmentary abnormalities.^[19] Similarly, mutations in the FGFR2 gene underlie craniosynostosis syndromes such as Apert and Crouzon syndromes, where telecanthus accompanies premature suture fusion, midface hypoplasia, and proptosis.^[20] Mutations in the FOXL2 gene cause blepharophimosis, ptosis, and epicanthus inversus syndrome (BPES), featuring telecanthus with eyelid abnormalities.^[21] NIPBL gene mutations are linked to Cornelia de Lange syndrome (CdLS), which includes telecanthus among distinctive facial dysmorphisms.^[22] Additionally, mutations in PITX2 or FOXC1 genes underlie Axenfeld-Rieger syndrome, often presenting with telecanthus and ocular anterior segment anomalies.^[23] Noonan syndrome, caused by mutations in genes such as PTPN11 in the RAS/MAPK pathway, can feature telecanthus with hypertelorism and low-set ears.^[24]^[25] Congenital non-genetic causes include environmental teratogens and chromosomal anomalies that disrupt embryonic facial morphogenesis. Fetal alcohol syndrome, resulting from prenatal alcohol exposure, frequently manifests with telecanthus, short palpebral fissures, and epicanthal folds due to disrupted neural crest cell migration.^[26] Down syndrome (trisomy 21) is linked to telecanthus as part of broader dysmorphic features, including epicanthus and hypertelorism, stemming from chromosomal imbalance affecting craniofacial growth.^[27] Acquired causes typically result from postnatal insults to the medial orbital structures. Trauma, particularly naso-orbito-ethmoid (NOE) fractures from blunt facial injury, disrupts the medial canthal tendon attachments, leading to traumatic telecanthus.^[28] Tumors, such as those in the naso-orbito-ethmoid region, can erode the medial orbit and cause telecanthus through mass effect or surgical resection.^[29] Risk factors for telecanthus align with its etiologic categories: family history of genetic disorders increases susceptibility to inherited craniofacial anomalies; prenatal alcohol exposure heightens the likelihood of fetal alcohol syndrome-related features; and high-impact facial trauma elevates the risk of acquired forms.^[5] Telecanthus rarely presents as an isolated trait and is usually syndromic, integrated within broader dysmorphic or structural abnormalities rather than occurring independently.^[30]

Clinical Presentation and Associations

Clinical Features

Telecanthus is characterized by a widened appearance between the inner corners of the eyes, known as the medial canthi, resulting from an increased intercanthal distance while the interpupillary distance remains normal.^[4] This primary sign often presents with epicanthal folds, which are skin folds extending from the upper eyelid over the medial canthus, contributing to the illusion of increased spacing.^[5] The condition is typically bilateral in congenital cases but can be unilateral following asymmetric trauma, such as naso-orbital-ethmoidal fractures that disrupt the medial canthal tendon.^[4] Patients with telecanthus are generally asymptomatic, with cosmetic concerns being the predominant issue due to the altered facial aesthetics.^[5] Rare functional symptoms may arise when telecanthus coexists with other ocular anomalies, including strabismus that affects eye alignment or exposure keratopathy leading to corneal irritation from inadequate eyelid closure.^[5] In congenital presentations, the feature is often noticeable in infancy, becoming more apparent in children as facial proportions develop, whereas acquired cases exhibit acute onset following trauma.^[4] Complications primarily involve psychological impacts, including diminished self-esteem from perceived facial disharmony, particularly in adolescents and young adults.^[5] Additionally, if associated with lacrimal system disruptions, secondary complications like recurrent infections or dacryocystitis may occur due to impaired tear drainage.^[31]

Associated Conditions

Telecanthus is frequently associated with craniofacial syndromes such as blepharophimosis-ptosis-epicanthus inversus syndrome (BPES), a genetic disorder characterized by underdeveloped eyelids, drooping of the upper eyelid (ptosis), and an inward fold of skin on the eyelids (epicanthus inversus), often leading to reduced visual field and requiring multidisciplinary management.^[32] Among genetic disorders, Waardenburg syndrome, particularly type 1, commonly features telecanthus (often as dystopia canthorum) alongside sensorineural hearing loss and pigmentary changes such as heterochromia iridis or premature graying of hair, with dystopia canthorum present in nearly all affected individuals and contributing to diagnostic criteria.^[33] Turner syndrome, caused by partial or complete absence of one X chromosome in females, is linked to telecanthus in conjunction with short stature, ovarian dysfunction, and congenital cardiac defects like coarctation of the aorta.^[4] Ehlers-Danlos syndrome, a group of connective tissue disorders due to collagen defects, manifests telecanthus with joint hypermobility, skin hyperextensibility, and fragility, potentially leading to vascular complications in certain subtypes.^[34] Other commonly associated conditions include Cri du chat syndrome, characterized by intellectual disability, microcephaly, and a high-pitched cry, and Klinefelter syndrome, involving an extra X chromosome in males with features like tall stature and hypogonadism.^[4] Other associations include craniosynostosis syndromes such as Apert, Crouzon, and Pfeiffer syndromes, where premature fusion of skull sutures results in midface hypoplasia, shallow orbits, and telecanthus, often accompanied by syndactyly or cognitive impairments.^[35] Fetal alcohol spectrum disorders, resulting from prenatal alcohol exposure, present telecanthus with growth delays, facial dysmorphisms like short palpebral fissures, and neurodevelopmental issues including intellectual disability.^[36] In Noonan syndrome, telecanthus co-occurs with renal anomalies (e.g., horseshoe kidney) or cardiac defects (e.g., pulmonary stenosis), alongside short stature and webbed neck.^[37] These conditions underscore systemic implications of telecanthus, with potential links to hearing deficits (as in Waardenburg syndrome), skeletal abnormalities (as in Ehlers-Danlos or Turner syndromes), or neurological involvement (as in fetal alcohol spectrum disorders or craniosynostosis), necessitating comprehensive evaluation for underlying etiologies often involving genetic mutations.^[33]

Diagnosis

Measurement Techniques

The primary method for measuring telecanthus in clinical settings involves direct anthropometry to assess the inner intercanthal distance (ICD), defined as the distance between the medial canthi of the eyes. This is typically performed using spreading calipers or a rigid ruler placed across the medial angles of the palpebral fissures, with the patient in a neutral head position and eyes in primary gaze.^[38]^[5] Measurements are taken twice for reliability, and the average is recorded to account for minor variations.^[38] Telecanthus is indicated when the ICD exceeds two standard deviations above age- and ethnicity-matched normative values; in adults, this threshold is generally greater than 35 mm, based on mean ICD values of approximately 30-31 mm with a standard deviation of 2-3 mm.^[39]^[8] For pediatric patients, norms vary by age, with values increasing from about 20 mm in infants to 24-30 mm in older children.^[6] Advanced imaging modalities are employed when bony or soft tissue abnormalities are suspected, particularly in traumatic or syndromic cases. Computed tomography (CT) scans provide detailed bony assessment of the medial orbital walls and nasal bridge, essential for evaluating trauma-related disruptions such as naso-orbito-ethmoidal fractures that may contribute to telecanthus.^[40] Magnetic resonance imaging (MRI) is used for soft tissue evaluation, including assessment of medial canthal tendon integrity and associated orbital structures, offering superior contrast without radiation exposure.^[4] Three-dimensional (3D) facial scanning, often via stereophotogrammetry, enables precise, non-invasive orbital analysis by generating surface models for quantitative distance measurements and volumetric assessments.^[41] Additional tools include calibrated photographic analysis, where standardized 2D frontal photographs are used to derive linear ICD measurements via software, providing a reproducible alternative for longitudinal monitoring.^[38] Ultrasound may assess medial canthal tendon integrity in select cases, though it is less commonly utilized for primary ICD quantification.^[4] Measurement of telecanthus forms part of a comprehensive craniofacial examination, which includes evaluation of interpupillary distance to confirm normal values and distinguish telecanthus from true orbital hypertelorism.^[4] This protocol ensures accurate diagnosis by integrating anthropometric data with clinical context.^[3]

Differential Diagnosis

Telecanthus requires careful differentiation from conditions that may simulate an increased medial canthal distance, as misdiagnosis can affect management of underlying craniofacial or syndromic issues. Accurate distinction relies on clinical measurements, such as the inner canthal distance (ICD), interpupillary distance (IPD), and outer canthal distance (OCD), alongside imaging when indicated.^[4] Hypertelorism presents with an increased IPD and interorbital distance due to lateral displacement of the bony orbits, affecting both inner and outer canthi, in contrast to telecanthus where only the ICD is elevated while the IPD and OCD remain normal. Differentiation is primarily achieved by measuring the IPD, which is typically 60-62 mm in adults for telecanthus but exceeds the 95th percentile (e.g., >65 mm) in hypertelorism; computed tomography (CT) further confirms normal orbital spacing in telecanthus.^[12]^[3] Blepharophimosis, frequently associated with blepharophimosis-ptosis-epicanthus inversus syndrome (BPES), involves true telecanthus combined with narrowed palpebral fissures (horizontal lid fissure <30 mm) and ptosis, unlike isolated telecanthus. Confirmation occurs via a full eyelid examination that identifies these additional structural abnormalities, often with genetic testing for FOXL2 mutations in suspected BPES cases.^[21]^[42] Epicanthal folds produce an apparent widening of the medial canthi due to skin redundancy over the inner eyelid corners, without an actual increase in ICD, commonly seen in conditions like Down syndrome or Asian ethnic variations. This illusion is resolved by gentle eversion or stretching of the folds during clinical examination, revealing a normal underlying ICD (typically 30-31 mm in adults), whereas true telecanthus persists.^[43]^[3] Pseudotelecanthus results from non-bony causes such as medial orbital swelling, scarring from prior trauma, or space-occupying lesions like tumors, leading to soft tissue distortion without alteration in the skeletal intercanthal distance. It is identified through imaging, particularly CT scans, which show preserved bony anatomy and no medial canthal tendon elongation, distinguishing it from congenital or traumatic true telecanthus.^[4]^[5] Other mimics include orbital tumors or fractures that do not disrupt the medial canthal tendon, such as isolated medial wall blowout fractures or benign neoplasms causing mass effect. These are differentiated by a detailed trauma history (absent in congenital telecanthus) and CT findings demonstrating no tendon avulsion or specific bony displacement at the medial canthal insertion, with potential resolution upon treatment of the underlying lesion.^[44]^[4]

Management

Non-Surgical Management

For mild and asymptomatic cases of telecanthus, particularly those that are congenital and isolated, observation is often the preferred approach, as intervention may not be necessary if there are no functional impairments or significant cosmetic concerns.^[5] This conservative strategy allows for natural facial development, especially in pediatric patients where the condition may appear less pronounced with growth.^[3] In syndromic telecanthus, such as that associated with blepharophimosis-ptosis-epicanthus inversus syndrome (BPES), genetic counseling is recommended to educate families on inheritance patterns, recurrence risks, and options for family planning.^[21] Counseling involves multidisciplinary input from geneticists to assess carrier status and provide personalized guidance, which can alleviate anxiety and inform reproductive decisions.^[45] Supportive care focuses on alleviating associated symptoms, such as epiphora, which can arise from medial canthal displacement affecting lacrimal drainage in craniofacial syndromes. Management includes the use of artificial tears to lubricate the ocular surface and relieve irritation, alongside lacrimal duct probing to address congenital or acquired obstructions contributing to tearing.^[46] Cosmetic options for telecanthus emphasize non-invasive techniques to enhance appearance and bolster self-esteem, including camouflage makeup applied to the medial canthal region or the use of spectacles to visually minimize the intercanthal distance. Psychological support, such as counseling or participation in support groups, is advised to address potential emotional distress from altered facial aesthetics, promoting better mental health outcomes.^[5] Regular monitoring through follow-up examinations is essential, especially in acquired cases following trauma, to evaluate progression, detect complications like worsening asymmetry, and determine if escalation to other interventions is needed.^[47] This involves periodic assessments of intercanthal distance and associated features, typically every 3-6 months initially, to ensure stability and timely adjustment of care plans.^[48]

Surgical Treatment

Surgical treatment for telecanthus is primarily indicated for cosmetic improvement in cases of significant deformity affecting self-esteem, functional correction in associated conditions like blepharophimosis-ptosis-epicanthus inversus syndrome (BPES) where it contributes to vision obstruction from ptosis or ectropion, and reconstruction in syndromic or traumatic etiologies such as naso-orbital-ethmoidal fractures.^[5]^[4]^[49] Common procedures include medial canthoplasty to reposition the medial canthal tendons, transnasal canthopexy involving wiring or suture fixation through the nasal bones for stable anchorage, and orbital osteotomy for bony advancement or repositioning in severe traumatic or congenital cases with underlying skeletal abnormalities.^[4]^[5] Techniques often incorporate shortening of the medial canthal tendon using Y-V plasty or Z-plasty incisions to address tendon laxity, with transnasal wiring providing the strongest fixation by securing the tendon to the medial orbital wall; in trauma, miniplates or micro-screws may be used for cantilevered fixation to restore anatomy.^[4]^[49]^[50] In children with congenital telecanthus, surgery is typically delayed until facial growth is more complete, around ages 3 to 5 years or school age, to optimize long-term stability and avoid interference with development, whereas traumatic cases may require immediate or early intervention within weeks to prevent malunion.^[5]^[51] Outcomes generally show high satisfaction rates, with mean reductions in intercanthal distance (IICD) of 6-8 mm in BPES cases and abolition of epicanthal folds without major scarring; however, risks include recurrence due to tendon loosening, asymmetry, infection, or overcorrection necessitating revision surgery.^[49]^[52]^[4]

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