Facial Nerve Paralysis: An Unrecognized Cause of Lower Eyelid Entropion in the Pediatric Population Nonette Y. Pasco, M.D.*, Don O. Kikkawa, M.D.*, Bobby S. Korn, M.D., Ph.D.*, Karim G. Punja, M.D.*, and Marilyn C. Jones, M.D.† *Division of Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology, Shiley Eye Center, University of California, San Diego, La Jolla, California; and †Department of Pediatrics, University of California, San Diego, Children’s Hospital San Diego, San Diego, California, U.S.A. Purpose: To describe the association between entropion and pediatric facial nerve paralysis in the pediatric population. Methods: A retrospective case series was collected from 5 pediatric patients who required surgical correction for symptomatic entropion with a history of facial nerve palsy. Results: All 5 patients presented with epiphora and punctate keratopathy. Following surgical correction of the entropion, all ocular symptoms resolved. Conclusions: To the best of our knowledge, this is the first report linking facial nerve paralysis with entropion in the pediatric population. Ophthalmologists and pediatricians should consider this in the evaluation of children with craniofacial abnormalities and facial nerve paralysis. P ediatric facial nerve (cranial nerve 7, CN VII) paral- ysis can be attributed to a variety of causes. The condition is generally considered to be developmental or traumatic in etiology. Craniofacial abnormalities such as the Mo ¨bius sequence, facio-auriculo-vertebral spectrum, and CHARGE syndrome have a reported incidence of facial paralysis in 8% to 25% of patients, with the remainder secondary to complications during delivery. 1 In adults, facial nerve paralysis typically presents with the triad of lagophthalmos, ectropion, and exposure kera- topathy. 2 Gravitational forces on the lower eyelid and cheek are unopposed by the paretic orbicularis muscle contributing to ectropion or eversion of the eyelid margin. 3 We recently examined 5 pediatric patients with facial paralysis who presented with lower eyelid entropion. All 5 patients had developmental craniofacial abnormalities of various causes in association with facial nerve paralysis. Only one previous case of pediatric paralytic entropion in Mo ¨bius syndrome, in association with strabismus, has been reported and facial paralysis was not a recognized etiology. 4 The goal of this study is to report the findings in our case series, to discuss the interplay of factors resulting in the development of entropion in pediatric facial paralysis, and to describe our methods of surgical repair. METHODS All patients presented to the Shiley Eye Center, University of California, San Diego Medical Center (both university-based referral centers), or Children’s Hospital of San Diego. The medical records of 5 pediatric patients with paralytic entropion were retrospectively reviewed. Data obtained included etiologic diag- nosis, nature of craniofacial anomalies, ophthalmic examination findings, description of surgery (if any), and length of follow- up. All patients had facial nerve palsy (unilateral or bilateral), and entropion on the side of facial palsy. Surgical correction was performed in all 5 cases. A full- thickness incision was approached through the tarsus posteri- orly 1 mm to 2 mm below the eyelid margin. The incision was extended horizontally for the full extent of the entropic eyelid segment. Blunt dissection was used to create a pocket between the superior tarsus and pretarsal orbicularis as shown in Figure 1A. Two or three double-armed 6-0 polygalactin sutures were then used in a horizontal mattress fashion to evert the eyelid margin. Each arm of the suture is passed from the inferior border of the tarsus in a partial-thickness fashion and directed through the newly created pocket between the pretarsal orbic- ularis and superior tarsus and directed just below the eyelash line. Each of the double-armed sutures is placed prior to tying them off (Fig. 1B). Figs. 1C and 1D show a graphical repre- sentation of the procedure. Each suture is then assessed for the amount of eyelid margin eversion and tied off separately (Fig. 2). The net result advances the lower eyelid retraction forces more anteriorly and superiorly, assisting the everting forces of the lower eyelid. 5–7 Accepted for publication September 7, 2006. This study was supported by the Bell Charitable Foundation, the Dr. Seuss Fund of the San Diego Foundation, and the Marie D. Shafer Family. Address correspondence and reprint requests to Don O. Kikkawa, MD, Shiley Eye Center, UCSD Department of Ophthalmology, 9500 Gilman Drive, La Jolla, CA 92093-0946; E-mail: dkikkawa@ucsd.edu DOI: 10.1097/IOP.0b013e318031d807 Ophthalmic Plastic and Reconstructive Surgery Vol. 23, No. 2, pp 126–129 ©2007 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. 126