To the Editor:
Chadwick and Lockington report a case of ipsilateral ocular discomfort with corneal staining and dry eye immediately following cataract surgery in a mask-wearing individual [1]. The authors attribute this to be directly related to the patient wearing an ill-fitting face mask and a manifestation of Mask-associated Dry Eye.
The upper eyelids in figure 1 show lash ptosis, more so on the left and mildly present on the right upper eyelid. In figure 2A, the pattern of corneal staining at the level of the upper eyelid margin and immediately inferior to this follow the contour of the upper eyelid margin. Lash ptosis and absence of the visible upper eyelid margin, suggesting meibomian gland inversion and an early marginal entropion is also seen in figure 2A. Figure 2B, taken 1 week later, shows a clear cornea and also, an improvement in upper eyelid margin position, with less upper eyelid margin entropion and less lash ptosis. More eyelid margin is visible.
We write to suggest that these findings would also be consistent with the presence of upper eyelid meibomian-gland inversion (MGI) and an early marginal entropion [2,3,4,5]. The presence of lash ptosis suggests a subtle marginal upper eyelid entropion may well have occurred, perhaps in a pre-disposed individual with MGI, and possibly, as a temporary consequence of the speculum. The patient’s symptoms and pattern of staining would also be consistent with this condition.
MGI occurs in a subgroup of meibomian gland dysfunction patients with a subtle, early but distinct variant of marginal upper eyelid entropion. It is frequently overlooked and underrecognised in daily clinical practice. On temporarily correcting the subtle upper eyelid margin malposition with an outward rotation and eversion of the anterior lamella using a cotton bud on the upper eyelid skin surface, most patients report a temporary relief of symptoms (the ‘cotton tip test’) [2].
References
Chadwick O, Lockington D. Addressing post-operative Mask-Associated Dry Eye (MADE). Eye. 2021;35:1543–4. https://doi.org/10.1038/s41433-020-01280-5
Siah WF, Boboridis K, Tan P, Litwin AS, Daya SM, Malhotra R. Meibomian gland inversion: under-recognized entity. Acta Ophthalmol. 2019;97:e1116–22. https://doi.org/10.1111/aos.14155.
Ullrich K, Malhotra R. Recognising meibomian gland inversion in patients with facial palsy to improve the ocular surface. Orbit. 2021;40:1–8. https://doi.org/10.1080/01676830.2019.1705500.
Samia-Aly E, Barua AR, Patel RP, Mehta P. Anterior lamellar repositioning in the management of meibomian gland inversion secondary to meibomian gland dysfunction. Ophthalmic Plast Reconstr Surg. 2021. https://doi.org/10.1097/IOP.0000000000001948.
Pandey N, Jayaprakasam A, Feldman I, Malhotra R. Upper eyelid levator-recession and anterior lamella repositioning through the grey-line: avoiding a skin-crease incision. Indian J Ophthalmol. 2018;66:273–7. https://doi.org/10.4103/ijo.IJO_774_17.
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Ali Ahmad, S.M., Malhotra, R. Comment on: ‘Addressing post-operative Mask-associated Dry Eye (MADE)’. Eye 36, 1846 (2022). https://doi.org/10.1038/s41433-021-01843-0
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DOI: https://doi.org/10.1038/s41433-021-01843-0