To the Editor:

We thank Ahmad and Malhotra for their interest in our recent paper describing a case of ocular surface breakdown in the immediate time-period following uneventful cataract surgery [1]. In our paper, we suggested that the mechanism of action for this corneal disruption was post-operative Mask-Associated Dry Eye (MADE), which resolved promptly with cessation of mask use and standard eyedrops [2]. Their oculoplastic review of our clinical images raised the possibility in their minds that the observed ocular signs could also be associated with upper eyelid meibomian-gland inversion (MGI) and an early marginal entropion [1].

We thank them for raising awareness of this under-recognised entity (MGI), their proposed surgical solutions and the further comments regarding the potential temporary impact of the eyelid speculum on the lid position. Although facemasks commonly cause mechanical malposition of the lower eyelid anatomy rather than the upper, we accept that their observations could be a further contributing factor in our case.

As our paper discussed, there are many potential mechanisms for ocular surface disruption following cataract surgery, including abnormal lid position, mechanical trauma and/or peri-operative medications causing epithelial toxicity. Environmental changes including facemasks (MADE) can further compound these factors. The recent Tear Film and Ocular Surface DEWSII pathophysiology report highlighted the vast multitude of mechanisms involved in the initiation and perpetuation of dry eye disease, which can all contribute to destabilising the ocular surface [3]. This case and the ensuing discussion demonstrates the timeless principle that the cornea is only as healthy as the surrounding environment (including the eyelids) permit it to be.