Sir,

Acquired entropion in children may happen as a result of ocular scarring following trauma, infection or surgery. Upper lid entropion in children is rare; Botulinum toxin injection has been suggested in literature to correct congenital entropion. Here we report for the first time a case of acquired lateral upper lid entropion in a child who was treated with a single injection of Dysport Botulinum toxin.

Case report

A 30-month-old Caucasian child presented with a 2-week history of eye rubbing and distress. No previous problems were reported. The lashes at the lateral end of the right upper lid were inverted (Figure 1). The lid was easily everted by lateral traction. His parents were instructed to reposition the lid. Unfortunately, the lateral entropion quickly recurred and a week later he was no better. His parents were very keen to avoid any surgery.

Figure 1
figure 1

Right eye upper lid entropion.

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Examination under anaesthetic was unremarkable; there was no foreign body or conjunctival scarring. The lid was repositioned and a single injection of 10 U of Dysport Botulinum toxin was given into the lateral part of the pretarsal orbicularis oculi (Figure 2).

Figure 2
figure 2

Injection of Botulinum toxin into the pretarsal orbicularis oculi.

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The entropion resolved. He has been followed-up for 15 months with only very, very occasional recurrence and that was managed with traction only.

Comment

Both congenital and acquired entropion occur in children. Orbicularis oculi muscle hypertrophy, orbicularis spasm, epiblepharon, and disinsertion of the lower lid retractors are suggested aetiologies of congenital entropion.1 Acquired entropion is attributed to ocular infection, scarring, previous surgery, and trauma.2

Upper lid entropion in children is rare. An Asian study reported successful surgical repair of upper lid entropion in 11 children.3 Christiansen et al4 reported a case of congenital lower lid entropion in a 3-week old baby that responded to 5 U injection of Botulinum toxin, although the type of Botulium toxin was not stated.

In our case the upper lid entropion did not recur after the Botulinum toxin worn off. We suggest two possible mechanisms, either the cycle of orbicularis spasm due to irritation from the entropion was broken by the treatment or that facial growth changed the balance of the inverting effect of the orbicularis over the stability of the posterior lamellae. Children with epiblepharon commonly improve as the midface grows during childhood.5

To our knowledge this is the first reported case of acquired lateral upper lid entropion in a child treated with Botulinum toxin. We suggest that this treatment could be used in children with entropion, where there is no obvious underlying cause.