Does cataract surgery in patients with concurrent lower lid malposition increase the risk of postoperative endophthalmitis

Objective: To evaluate the safety of performing cataract surgery prior to eyelid (entropion/ectropion) surgery in patients with concurrent cataract and lower eyelid malposition. Design: Retrospective case series. Participants and Methods: Patients with concurrent lower eyelid malposition and cataract undergoing cataract surgery before lower eyelid repair from 2013 to 2020 were identified from two ophthalmologists (M.L.W., G.R.). Both surgeries were performed by the same ophthalmologist, with eyelid repair completed at least 1 month following cataract extraction. Data analysis was performed with two-parameter estimations. The primary outcome was the postoperative endophthalmitis rate in this cohort. Results: 129 cases in 90 patients were found (86 involutional entropion and 43 involutional ectropion). No cases of endophthalmitis were encountered. Statistical analysis using the 95% Jeffreys interval for one-sample binomial proportion revealed an upper limit of 1.9%. The Agresti-Caffo interval of the proportional difference between the study procedure and historical incidence data of postoperative endophthalmitis following cataract surgery alone yielded an estimate of 0.8% with an upper confidence limit of 2.2%. Conclusion: We present preliminary evidence on the endophthalmitis risk in patients with concurrent lower eyelid malposition and cataract who undergo cataract surgery prior to eyelid repair. We propose that this strategy may be a viable option to expedite vision restoration and reduce the risk of recurrent lower eyelid malposition in select patients. More data are required to reach statistically significant noninferiority and show that a malpositioned lower eyelid is not a risk factor for postoperative endophthalmitis following cataract surgery.