|Year : 2013 | Volume
| Issue : 2 | Page : 55-59
Association between gender, age and palpebral dimensions/exophthalmometric values among Nigerians of Ido local government area of Oyo State, Nigeria
Waheed Ademola Ibraheem1, Anifat B. Ibraheem2, Charles O. Bekibele3
1 Department of Ophthalmology, Ladoke Akintola University of Technology, Ogbomoso, Nigeria
2 Department of Family Medicine, University College Hospital, Ibadan, Oyo State, Nigeria
3 Department of Ophthalmology, University College Hospital, Ibadan, Oyo State, Nigeria
|Date of Web Publication||20-Jun-2014|
Waheed Ademola Ibraheem
Department of Ophthalmology, Ladoke Akintola University of Technology, Ogbomoso, Oyo State
Source of Support: None, Conflict of Interest: None
Background: Knowledge of factors that could affect exophthalmometric and palpebral's measurement are important in clinical for the correct interpretation of these parameters. Among these factors are age and sex. Aims and Objectives: The objective of this study is to describe the relationship between gender, age and palpebral dimensions/exophthalmometric values (EV) among Nigerian. Materials and Methods: In a descriptive cross -sectional survey, EV and palpebral dimensions were measured in 1020 eligible and consented adults Nigerians using Hertel's exophthalmometer and non -stretchable plain plastic ruler respectively. Results: The studied population comprised of 1020 subjects including 515 females and 505 males. In the male subjects, the mean (mm) palpebral fissure width, palpebral fissure height, upper eyelid crease, margin reflex distance, lateral canthal distance, medial canthal distance, inter inner canthal distance and inter outer canthal distance were; 32.6 ± 2.8, 8.3 ± 1.4, 6.9 ± 1.6, 3.2 ± 1.2, 12.8 ± 2.0, 10.1 ± 0.9, 39.9 ± 3.2, 99.5 ± 5.6 respectively. Males had a significantly higher EV compared with females (15.5 ± 2.5 mm vs. 15.1 ± 2.4 mm, P = 0.0005). Conclusion: In this study, we described the relationship between gender, age and EV/palpebral dimension in African population. The knowledge of this relationship is valuable in the early diagnosis of the eyelid and orbital diseases, manufacturing of spectacles as well as achieving a satisfactory cosmetic eyelid surgery.
Keywords: Canthal distance, exophthalmometry, inter canthal distance, margin reflex distance, palpebral fissure
|How to cite this article:|
Ibraheem WA, Ibraheem AB, Bekibele CO. Association between gender, age and palpebral dimensions/exophthalmometric values among Nigerians of Ido local government area of Oyo State, Nigeria. Afr J Med Health Sci 2013;12:55-9
|How to cite this URL:|
Ibraheem WA, Ibraheem AB, Bekibele CO. Association between gender, age and palpebral dimensions/exophthalmometric values among Nigerians of Ido local government area of Oyo State, Nigeria. Afr J Med Health Sci [serial online] 2013 [cited 2021 Feb 27];12:55-9. Available from: http://www.ajmhs.org/text.asp?2013/12/2/55/134890
| Introduction|| |
The normal functional values of eyelids vary widely between sex and age.  Therefore, the knowledge of the average dimensions of periocular structures and the relationships between individual segments of the face based on age, gender and race is critical for eyelid surgeons so that complications can be avoided and satisfactory outcomes can be achieved. 
Existing are varying summations on the relationship between age, gender and palpebral dimensions. ,, van den Bosch et al.  reported about 10% increase in the size of the palpebral fissure width (PFW) between the ages of 12 and 25 and a similar reduction thereafter. Furthermore, van den Bosch et al.  reported a continuous increase in the upper eyelid crease (UEC) height with age due to senile related disinsertion of the levator muscle aponeurosis and involutional atrophy of the orbital fat.
The opinions on the relationship between gender and palpebral dimensions are diverse. While some of the authors , posited that the values are higher in the males, others  opined in the contrary. The differences in the values had been attributed to genetic composition and hormonal effect. Similarly, the amount of normal ocular protrusion (exophthalmometry) in an individual had also been reported to be a product of robust relationship between age and gender.
In a study among children of Chinese origin, Quant and Woo  demonstrated that the ocular prominence increases from birth to the late teens because of facial modeling and/or increase in orbital soft -tissue volume. However, the effect of aging on the adult population was not considered. Other authors, , had demonstrated a decrease in ocular prominence values as individual ages. Kashkouli et al.  attributed involutional orbital soft tissue atrophy as a cause for such a decrease. Ahmadi et al.  reported a general trend of exophthalmometric value (EV) to increase during first two decades of life, stabilize or a linear decrease during adulthood (third to sixth decade) and decreases in later decades (seventh decade onwards). In a study conducted among Indian population, Kumari Sodhi et al.  concluded that EV increased from second to third decades of life. The increase in EV in the early decades was attributed to a posterior movement of the orbital rim and the increase in orbital fat. However, a previous study conducted among adult Nigerians by Majekodunmi and Oluwole  in agreement with other author  reported no relationship between age and EV. Regarding the relationship between gender and EV, in existence are conflicting reports.
Although some authors, ,, reported a higher value among males, others , reported a higher values in a female subject, whereas, Kashkouli et al.  reported no significant difference between males and females. Beden et al.  posited that the variations in the findings might be related to racial differences or less probably to the different sample size in different studies. However, Kaye et al.  attributed the bigger stature of males as the reason for the higher values obtained in male subjects. However, it has not been previously investigated if age and sex have effect on EV/palpebral dimensions among Nigerian populace. Therefore, it is desirable to find out what relationship exists between age, sex and EV/palpebral dimensions among Nigerians.
| Materials and Methods|| |
This was a multi -staged descriptive cross -sectional study done among adult Nigerians with normal orbital/ocular status. Participants were recruited from Ido local government area (LGA) of Oyo state through multistage random sampling with probability proportional to size procedure. Five wards were selected by random sampling technique from the 10 wards in the LGA. Four settlements were then selected in each ward by balloting. Thereafter, houses within the selected settlements were numbered. In the final sampling stage, at least 40 people aged 16 years and above were recruited each settlement by cluster sampling technique; depending on the population of each settlement. This was continued until the required number of sample size was interviewed and examined.
Duration of the study: 6 months
Ethical approval was gotten from the hospital ethical committee.
Permission was sought from the traditional rulers of each village while informed written consent was obtained from all the subjects.
The study was conducted according to the guidelines by Helsinki's declarations on human research.
The materials used in the study included; Hertel's exophthalmometer, Plain non -stretchable plastic millimetre rule.
A subject fulfilled the following conditions: Persons 16 years and above who voluntarily consented to participate, no history of previous eye/orbital trauma, no previous periocular or ocular surgery, orbital or eyelid diseases that can affect the measurements such as orbital cellulitis, blepharitis and eyelid tumors and ocular infections, no history of thyroid eye disease, no facial abnormalities, does not have anophthalmos.
Exophthalmometry was done using Hertel's exophthalmometer following the guidelines described by Kumari Sodhi et al.  while palpebral dimensions were measured with non -stretchable transparent plastic millimeter ruler using the method described by Faruk and co -investigator.  All the parameters were measured in the primary position of gaze except UEC, which was done at down gaze. The two eyes were assessed sequentially, with the right eye done first.
Data was entered and analyzed using the statistical package for the social sciences version 17 manufactured by SPSS Inc. Released 2008. SPSS Statistics Windows, Version 17.0. Chicago: SPSS Inc. The comparison of mean palpebral dimensions, EV and categories of qualitative variables was done using the t -test and analysis of variance as applicable. Level of significance for all tests was at 5%.
| Results|| |
A total of 1020 subjects were studied including 515 males and 505 females and their age ranged between 16 and 85 years with a mean ± SD of 46 ± 14.4 years.
[Table 1] shows the palpebral fissure height (PFH) and PFW across age groups and gender. There was no significant difference in the mean PFH and PFW across age groups, though, there appeared to be a reduction with increase age. Male subjects had a significantly higher PFW (P < 0.001). No significant gender difference in the mean PFH (P = 0.532).
As shown in [Table 2], females had a statistical significantly higher UEC compared with their male counterparts (6.9 ± 1.6 vs. 7.2 ± 1.7, P = 0.008). Though, the mean UEC tends to increase with age, the difference was not statistically significant. There were no significant differences in measured margin reflex distance between categories of age and gender.
[Table 3] shows mean lateral canthal distance and medial canthal distance (LCD and MCD respectively) for different age group and sex. There was a consistent decline in the value of LCD with increase age, which was statistically significant (P < 0.001). The mean LCDs for male and female respondents were 12.8 ± 2.01 mm and 13.0 ± 1.7 mm. The mean MCD was significantly higher in the males (10.1 ± 0.9 mm vs. 9.8 ± 1.0 mm, P ≤ 0.001. There was a consistent decline in LCD with age group, which was statistically significant (P < 0.001). There was no significant difference in mean MCD between the age groups (P = 0.124), but there was a significantly higher mean MCD for males compared to females (P < 0.001).
The inter (inner and outer) canthal distances (IICD and IOCD) varied significant across the age groups, but there was no particular trend. The lowest value of IICD and IOCD were in the age group 50 -59 years. Male subjects had a statistically significant higher IOCD and IICD compared with their female counterparts (P < 0.001). The details are as shown in [Table 4].
|Table 4: Lateral and medial inter-canthal distances across age group and gender|
Click here to view
The EV increased between the age group less than 30 to age group 40 -49 years and then decreased. Thereafter, there was another peak at age group 50 -69 years followed by another decrease. EV was significantly higher in male subjects (15.5 mm vs. 15.1 mm, P = 0.005). Other details are as shown in [Table 5].
| Discussion|| |
In this study, the PFH varied little with increasing age in agreement with the findings of Price et al.  This is likely to be due to the simultaneous occurrence of ptosis and lower lid laxity with advance age.
The mean PFH was higher among female subjects in consonance with a previous assertion.  However, the difference was not statistically significant. The observed difference could be due the variations in the facial skeletal build -up of male and females.  The genetic composition and hormonal make up could also responsible for this difference.
There was a little change in the PFW values with increase age in the studied population in an agreement with the findings of Boboridis et al.  This may be due to the fact that final adult facial skeletal configuration is attained at puberty and as the studied population consist of people of aged 16 years above, the finding was not surprising.
Higher PFW was obtained among the male subjects in consonance with some earlier workers , but in contradistinction to others.  This difference reflect the potential different pattern of craniofacial growth resulting from gender difference.
In this study, there was no significant difference in the medial and LCDs across all age groups in agreement with a previous investigator.  However, males had a significantly higher mean MCD. This higher value in males is not unlikely to be due to hormonal influence on the craniofacial growth.
The higher mean inter canthal distances among the male subjects is in agreement with the findings of some previous investigators. , This finding may not be unrelated to the heavier nature of men, his genetic make -up and the higher bone density.
Although, there was a significant difference in the inter outer -canthal distances across age groups, no particular trend could be demonstrated. This observation may be a pointer to the existence of other factors that influence the palpebral dimensions asides age and gender. This finding could also be a reflection of varying pattern of craniofacial growth resulting from a complex interaction between genetic compositions, sex and nutrition of an individual.
In this study, UEC was significantly higher in the female subjects. This was consistent with the findings of Erbagci et al.  but in contradistinction to the summation of Nucci et al.  The higher value in female could be due to a supernatural design which usually tends toward making females more beautiful. Although, there was no significant difference in the value of UEC across all age groups in agreement with Erbagci et al.,  the highest mean UEC was found in older age group ( >60 years) in consonance with the findings of Murchison et al.  This finding is likely to be due to age -related disinsertion of the levator muscle aponeurosis coupled with the involutional atrophy of the orbital fat.
There are varying reports on the effect of gender on EV. While some authors , reported no significant gender difference, others ,, obtained higher values in males, whereas some authors , found a higher value in females. Racial differences had been implicated as a cause for this dissimilar findings.  In this study, EV was higher in male subjects by 0.43 mm, the difference though, was statistically significant it may not be clinically significant since EV's value is usually performed with 1 mm increments. However, this finding may be a true reflection of gender influence on the EV among the studied population. The differences in genetic and skeletal buildup of male and female and the bigger stature of males could be responsible for the difference obtained in this study.
In this study, no specific pattern of change in EV could be demonstrated with ageing consonance with the findings of some previous authors. ,
| References|| |
|1.||Mourits MP, Lombardo SH, van der Sluijs FA, Fenton S. Reliability of exophthalmos measurement and the exophthalmometry value distribution in a healthy Dutch population and in Graves' patients. An exploratory study. Orbit 2004;23:161 -8. |
|2.||Nkenke E, Maier T, Benz M, Wiltfang J, Holbach LM, Kramer M, et al. Hertel exophthalmometry versus computed tomography and optical 3D imaging for the determination of the globe position in zygomatic fractures. Int J Oral Maxillofac Surg 2004;33:125 -33. |
|3.||Price KM, Gupta PK, Woodward JA, Stinnett SS, Murchison AP. Eyebrow and eyelid dimensions: An anthropometric analysis of African Americans and Caucasians. Plast Reconstr Surg 2009;124:615 -23. |
|4.||Zamora RL, Becker WL, Custer PL. Normal eyelid crease position in children. Ophthalmic Surg 1994;25:42 -7. |
|5.||van den Bosch WA, Leenders I, Mulder P. Topographic anatomy of the eyelids, and the effects of sex and age. Br J Ophthalmol 1999;83:347 -52. |
|6.||Etezad -Razavi M, Jalalifar S. Correlation between interpupillary and inner -outer intercanthal distances in individuals younger than 20. J Ophthalmic Vis Res 2008;3:16 -22. |
|7.||Kaimbo DK, Kayembe D. [Orbital measurements in Zairian children. Inner canthal, outer orbital, inter -pupillary distances and proptosis]. J Fr Ophtalmol.1994;17:496 -500. |
|8.||Quant JR, Woo GC. Normal values of eye position and head size in Chinese children from Hong Kong. Optom Vis Sci 1993;70:668 -71. |
|9.||Kaye SB, Green JR, Luck J, Lowe KJ. Dependence of ocular protrusion, asymmetry of protrusion and lateral interobital width on age. Acta Ophthalmol (Copenh) 1992;70:762 -5. |
|10.||Quant JR, Woo GC. Normal values of eye position in the Chinese population of Hong Kong. Optom Vis Sci 1992;69:152 -8. |
|11.||Kashkouli MB, Nojomi M, Parvaresh MM, Sanjari MS, Modarres M, Noorani MM. Normal values of hertel exophthalmometry in children, teenagers, and adults from Tehran, Iran. Optom Vis Sci 2008;85:1012 -7. |
|12.||Ahmadi H, Shams PN, Davies NP, Joshi N, Kelly MH. Age -related changes in the normal sagittal relationship between globe and orbit. J Plast Reconstr Aesthet Surg 2007;60:246 -50. |
|13.||Kumari Sodhi P, Gupta VP, Pandey RM. Exophthalmometric values in a normal Indian population. Orbit 2001;20:1 -9. |
|14.||Majekodunmi S, Oluwole M. Exophthalmometry in Nigerians. West Afr J Med 1989;8:35 -7. |
|15.||Migliori ME, Gladstone GJ. Determination of the normal range of exophthalmometric values for black and white adults. Am J Ophthalmol 1984;98:438 -42. |
|16.||Dunsky IL. Normative data for hertel exophthalmometry in a normal adult black population. Optom Vis Sci 1992;69:562 -4. |
|17.||Beden U, Ozarslan Y, Oztürk HE, Sönmez B, Erkan D, Oge I. Exophthalmometry values of Turkish adult population and the effect of age, sex, refractive status, and Hertel base values on Hertel readings. Eur J Ophthalmol 2008;18:165 -71. |
|18.||Oztürk F, Yavas G, Inan UU. Normal periocular anthropometric measurements in the Turkish population. Ophthalmic Epidemiol 2006;13:145 -9. |
|19.||Vasanthakumar P, Kumar P, Rao M. Anthropometric Analysis of Palpebral Fissure Dimensions and its Position in South Indian Ethnic Adults. Oman Med J 2013;28:26 -32.. |
|20.||Boboridis K, Assi A, Indar A, Bunce C, Tyers AG. Repeatability and reproducibility of upper eyelid measurements. British journal of ophthalmology 2001;85:99 -101. |
|21.||Park DH, Choi WS, Yoon SH, Song CH. Anthropometry of Asian eyelids by age. Plast Reconstr Surg 2008;121:1405 -13. |
|22.||Cartwright MJ, Kurumety UR, Nelson CC, Frueh BR, Musch DC. Measurements of upper eyelid and eyebrow dimensions in healthy white individuals. Am J Ophthalmol 1994;117:231 -4. |
|23.||Murchison AP, Sires BA, Jian -Amadi A. Margin reflex distance in different ethnic groups. Arch Facial Plast Surg 2009;11:303 -5. |
|24.||Farkas LG, Forrest CR, Litsas L. Revision of neoclassical facial canons in young adult Afro -Americans. Aesthetic Plast Surg 2000;24:179 -84. |
|25.||Oladipo GS, Okoh PD, Hart JS. Anthropometric study of ocular dimensions in adult ijaws of Nigeria. Res J Med Med Sci 2010;5:121 -4. |
|26.||Erbagci I, Erbagci H, Kizilkan N, Gumusburun E, Bekir N. The effect of age and gender on the anatomic structure of Caucasian healthy eyelids. Saudi Med J 2005;26:1535 -8. |
|27.||Nucci P, Brancato R, Bandello F, Alfarano R, Bianchi S. Normal exophthalmometric values in children. Am J Ophthalmol. 1989;108:582 -4. |
|28.||Smolders MH, Graniewski -Wijnands HS, Meinders AE, Fogteloo AJ, Pijl H, de Keizer RJ. Exophthalmos in obesity. Ophthalmic research 2004;36:78 -81. |
|29.||Barretto RL, Mathog RH. Orbital measurement in black and white populations. Laryngoscope 1999;109:1051 -4. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]