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A 67-year-old woman developed progressively worsening bilateral ectropion over 2 months, subsequently with fluctuating dysarthria. She had been previously well. On examination, there was a bilateral lower lid ectropion (figure 1A-C) but with only mild weakness of the orbicularis oculi muscles. Her speech was slurred, worsening progressively with continued talking. There were no other neurological signs.