To the Editor:

I read “When Plastics Issues Complicate Cataract Surgery” (July 2013), and this article is certainly of interest, especially regarding both postoperative ptosis, as well as lower lid problems that may follow an otherwise uncomplicated cataract procedure.
Entropion following a cataract procedure has also been reported1 and, although infrequent, it should be discussed as a possible postoperative occurrence which might require surgical correction.

In many ways, postoperative entropion is analogous to the more commonly developing postoperative ptosis,1 and advancement or re-attachment of the capsulopalpebral fascia to repair this is analogous to repair of the dis-inserted or thinning of the levator aponeurosis for upper lid repair.

Feldstein describes a three-suture technique,2 and indeed advancing the dehisced retractor may stabilize the inferior tarsal border from rotating forward, thereby correcting the entropion, just as advancing the thinned or disinserted levator aponeurosis may solve postoperative ptosis—since they are analagous structures.

Involutional entropion has several contributing causes,3 one of which is dis-insertion of the capsulopapebral fascia from the inferior tarsal border followed by pre-septal orbicularis moving upward to override the pre-tarsal orbicularis,4 resulting in entropion. Although usually not associated with any inciting ocular irritation, cataract surgery has indeed been reported to directly precede, and likely to have contributed, to the postoperative entropion in a number of reported cases.

This possibility of postoperative entropion that might need surgical correction, reported by a number of sources, should therefore be discussed with the prospective cataract patient along with discussion of the other conditions thoroughly noted in your article. Preoperative findings of horizontal lower lid laxity, another predisposing cause for entropion, might make this discussion a priority even in an individual with good lower lid position.

Stuart M. Terman, MD
Solon, Ohio 44139

1. Levine MR, Enlow MK, Terman SM. Spastic Entropion After Cataract Surgery Ann Ophthalmology 1992:24:195-198.
2. Feldstein M. A method of surgical correction of entropion in aged persons. Ear Nose Throat J 1960:39:730-731.
3. Levine MR. Involutional entropion. Geriatric Ophthamology 1986:1:14-21.
4. Jones CT. The anatomy of the lower eyelid and the cause and cure of entropion. Am J Ophthalmol 1960:49:29-36.