Sir,

We read with great interest the article by D Shome et al, ‘Ptosis caused by orbicularis myokymia and treated with botulinum toxin’.

We wish to raise the following points:

The patient did not have a ptosis but blepharospasm, resulting in a decrease in palpebral aperture size in the left eye compared to the right.

The fact that the left upper lid was relatively lower than the right would presumably be a function of increased left orbicularis oculi tone relative to the right.

Furthermore, comparing the two photographs Figure 1a and Figure 2, it would appear that the patient had been squinting, that is, the palpebral apertures on the right eye were also greater in Figure 2 compared to Figure 1a. The authors have not made any attempt to explain this. Was there in fact an element of right blepharospasm? Did they make electromyographic recordings from the right eye?

How do they explain the increase in right-sided palpebral aperture size between the figures, given that botulinum toxin was only injected around the left eye?