Sir,

We wish to thank Dr Malik et al for their interest in our article ‘Ptosis caused by orbicularis myokymia and treated with botulinum toxin—a case report’.

We agree that this patient did not have actual ptosis. In fact, the first line of the discussion of our published article1 states ‘Overactivity of the orbicularis oculi presents with a reduced palpebral aperture simulating ptosis, due to a disparity between the eyelid closing (orbicularis oculi) and eyelid opening (levator palpebrae superioris) muscles’. The patient's complaint was ptosis and she was referred to us for treatment of ptosis; Dr Malik and Dr Joshi would appreciate that the mention of ‘ptosis’ was made by us with reference to the appearance of the left eye and not the pathology per se.

This case was interesting as there were no obvious fibrillations of the left upper or lower eyelids seen, even on prolonged examination under magnification—so the overactivity of the orbicularis oculi muscle was not readily apparent. Hence, electromyography of the left orbicularis oculi muscle was deemed necessary—this became even more essential when the patient, a very well informed young lady, demanded objective evidence of our diagnosis. The electromyography of the right eye was performed as a control and did not demonstrate the repetitive grouped motor potentials, seen on the left side. Real-time evaluation did not suggest any reduction of the palpebral aperture on the right side. The patient has been under follow-up for greater than 18 months now, with no recurrence in the condition.