Cataract Surgery Before Eyelid Repair Does Not Raise Endophthalmitis Risk

two doctor doing cataract surgery in operating room
Many surgeons chose to perform eyelid procedures first because to reduce eye irritation and chances for postoperative endophthalmitis, according to a survey.

A study shows that, while surgeons may have several reasons to perform eyelid repair before cataract surgery when a patient presents with both, greater risk for endophthalmitis is not among them. In a survey of local clinicians by the Department of Ophthalmology at University of Manitoba, Canada, 61% reported that they chose to do eyelid procedures first because there might be less eye irritation and fewer chances for postoperative endophthalmitis.

The retrospective case series published in the Canadian Journal of Ophthalmology  evaluated outcomes of 90 patients, average age 78 years, with cataract and coexisting lower eyelid involutional entropion (86) or involutional ectropion (43) — with 39 bilateral cases. Participants received cataract surgery first, and lid repair at least 1 month later, during the study period from 2013 to 2020. Participants with acute corneal ulcers were excluded, as were those who underwent cataract and lid surgeries performed by 2 different ophthalmologists. 

Chart data included the assessments between and after surgeries: eyelid position, ocular discomfort, discharge, corneal fluorescein staining, examination of the conjunctiva, anterior chamber, and vitreous, and best-corrected visual acuity (BCVA). With the sequence of cataract extraction prior to lid repair, no surgical complications, vitritis, or endophthalmitis occurred after either procedure. Mean BCVA improved from 20/50 to 20/40 at about 2 weeks after surgery.

“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,” according to the investigation, also noting a lesser known but possible risk of lid malposition that can follow procedures using an eyelid speculum. The speculum is thought to be a potential cause of lateral canthal tendon stretch, and to increase the chance for injury to the capsulopalpebral fascia.

Approximately 1% to 2% of patients with cataract who visit the 2 study clinicians also present with concurrent lower lid conditions. In this case, a lateral tarsal strip (LTS) is typically used along with appropriate sutures for entropion or ectropion — and the lateral canthotomy needed for LTS may raise infection risk. Thus, lid repair and phacoemulsification are not performed on the same occasion at this clinic. In preparing for cataract surgery, topical antibiotics, 10% povidone-iodine external wash, and 5% povidone-iodine conjunctival cul-de-sac rinse are used, as well as an intracameral antibiotic for any surgical complication, such as posterior capsule rupture.

A limitation of this study is that it may be statistically underpowered. To prove that the cataract-surgery-first sequence is noninferior, a larger sample is required, researchers found. However, by using postcataract endophthalmitis rates from current literature as a stand-in control group for this analysis, investigators calculated with 95% certainty that postoperative endophthalmitis incidence is undetermined, but less than 2.2%, and patients should be counseled accordingly.

Individuals who need immediate vision improvement for work, driving, or to prevent falls could benefit from a surgical sequence of cataract extraction before eyelid repair, the study explains. 


Yarmak P, Lee-Wing M, Rocha G. Does cataract surgery in patients with concurrent lower lid malposition increase the risk of postoperative endophthalmitis? Can J Ophthalmol. Published online May 29, 2021. doi:10.1016/j.jcjo.2021.04.024