Chalazia Removal

Thomas B. Redens, MD
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Subject: Chalazia Removal

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Introduction

Chalazia appear as chronic subcutaneous nodules of the eyelid. Chalazia develop from obstruction of the meibomian gland duct at the eyelid margin and almost always have a radial orientation to the lid margin. Leaking sebaceous material from an engorged, obstructed gland induces lipogranulomatous inflammation. Chalazia usually are sterile, although lesions frequently become secondarily infected. 
Chalazia are often confused with hordeolums or styes. Hordeolums are associated with infection of a meibomian gland (or other accessory eyelid gland) and manifest as suddenly appearing, erythematous, tender lumps in the eyelids that usually form abscesses and drain spontaneously. Although hordeolums usually are self-limited, they can evolve into chalazia with chronicity. 
Keeping in mind two important differentiators between chalazia and hordeola will minimize diagnostic confusion: (1) Hordeola are quite painful, while chalazia are usually painless, and (2) Chalazia are chronic, while hordeola are usually acute. Chalazia often appear in individuals with skin disorders such as seborrheic dermatitis or rosacea and are highly associated with blepharitis. 
Conservative care is frequently all that is needed for successful treatment of chalazia, as opening of the duct will often result in resolution of the inflammation. The application of warm moist compresses four times daily should be the initial therapy. Patients are instructed to use a clean washcloth soaked in hot water (emphasize—not scalding!) and to hold this washcloth against their closed eyes. When the water cools, the patient is to reheat the washcloth and repeat the compress. This should be done for several minutes. Along with the compresses, basic lid hygiene is essential. The patient should use baby shampoo for lid scrubs by placing a drop of the shampoo on their fingertip and gently massages the lid margin/lash line while the eye is closed. More than one third of lesions will resolve over 3 months with this therapy, although usually 1 month of warm compress therapy is usually sufficient to identify those who will respond to conservative management. 
The second tier of conservative therapy is antibiotic therapy. The most commonly used agents are tetracycline (250 mg BID) or doxycycline (100 mg qd). Usually, results are seen within 1 to 2 months after starting this therapy. Antibiotic therapy is quite useful in preventing recurrence, and the patient must continue the regimen of warm compresses and lid hygiene. Importantly, prior to initiation of either warm compresses/lid hygiene with or without antibiotic therapy, the clinician should physically palpate the chalazia—if the nodule is hard, more aggressive measures are needed. 

Equipment

For intralesional steroid injections: 
  • Tuberculin syringe with a 30-gauge needle

  • 0.05 to 0.2 mL triamcinolone (5 mg/dL)

  • Proparacaine 1% or tetracaine 0.5%

For incision and curettage: 
  • 1% lidocaine without epinephrine

  • Proparacaine 1% or tetracaine 0.5%

  • Plastic corneal shield

  • Ophthalmic ointment

  • Chalazion forceps

  • No. 11 blade

  • Chalazion currette

Indications

  • Chronic internal eyelid nodules, often with recurrent nature

  • Cosmetic deformity from chalazia

  • Chronic irritation from chalazia

  • Visual disturbance (induction of astigmatism) from chalazia

Contraindications

  • Hordeolums (self-limited)

  • Chalazia that have not undergone conservative management

  • Chalazia associated with chronic unilateral blepharitis or loss of eyelashes due to the possibility of malignancy—especially sebaceous cell carcinoma

  • Chalazia associated with cicatrizing eye disorders (i.e., ocular cicatricial pemphigoid, Stevens-Johnson syndrome)

  • Darkly pigmented patients (depigmentation associated with intralesional steroid)

The Procedure

Intralesional Triamcinolone

Step 1
Stabilize the patient’s head. The patient should be in the supine position, and an assistant may be needed to immobilize the patient’s head. Inject 0.05 to 0.2 mL of the triamcinolone solution into the chalazion. If using the external approach, position the needle obliquely to avoid possible injury to the globe. 
Step 2
If approaching internally, administer 1 drop of anesthetic (proparacaine or tetracaine), and stabilize the lid. Instilling gel lidocaine (2% to 4%) into the inferior cul-de-sac and having the patient keep the eyes closed for several minutes prior to the injection allows good conjunctival anesthesia and substantially decreases patient discomfort. Use gentle pressure over the injection site to minimize bleeding. 
  • PEARL: Remember to include skin depigmentation and ocular injury in the consent.

Incision and Curettage

Step 1
Stabilize the patient’s head. The patient should be in the supine position, and an assistant may be needed to immobilize the patient’s head. The use of gel lidocaine is strongly encouraged. The figure shows a patient with a large inferonasal chalazion (with a small external component that has been partially expressed). Place a plastic corneal shield following the topical anesthesia. The shield is placed by having the patient look down while the clinician gently elevates the upper lid and then slides the shield under the upper lid. A suction cup device is also available for placement and removal of the corneal shield. 
  • PITFALL: The corneal shield may interfere with placement of the chalazion forceps.

Step 2
Administer approximately 0.2 mL of lidocaine without epinephrine subcutaneously over the chalazion. Then, apply the chalazion forceps. The flat plate of the forceps is external (on the skin), while the open ring is positioned on the conjunctival surface to encircle the chalazion. Chalazion forceps have a thumbwheel to tighten and hold the lid. Do not overtighten. At this point, the forceps are used to evert the lid and thus give exposure to the chalazion. 
  • PITFALL: This step usually gives incomplete anesthesia, as the tarsus is difficult to completely anesthetize.

  • PEARL: Use great care in everting the eyelid using these forceps, as disinsertion of the levator may occur with resultant permanent ptosis.

Step 3
Using the no. 11 blade, carefully incise over the chalazion (3 mm usually is adequate). Do not make the incision full thickness (through to the skin) or through the lid margin. 
Step 4
Using the chalazion curette, gently remove all the lipogranulomatous inflammatory material from the cavity, including scraping all walls. 
Step 5
Carefully remove both the curette and the forceps from the lid, and apply gentle pressure with gauze. The figure shows the patient’s lid after completion of the curettage, with gentle pressure being applied to the site with a cotton-tipped applicator. 
  • PITFALL: Note that with intralesional steroid injection or incision and curettage, have the patient sit up slowly. Vasovagal reactions are quite common with these procedures.

Complications

  • Recurrence of chalazion

  • Skin depigmentation (in darkly pigmented individuals)

  • Infections (uncommon secondary to the rich vascular supply of the lids)

  • Bleeding (ask the patient about anticoagulant medications or bleeding disorders)—also usually not a significant problem

  • Ptosis (after use of chalazion forceps)—more common in the elderly

  • Conjunctival scarring—rare, associated with large incisions and other ocular diseases (i.e., ocular cicatricial pemphigoid).

  • Central retinal artery occlusion (rare)—associated with periocular steroid injections (including the lids)

  • Ocular injury

Pediatric Considerations

Generally, children (or the mentally challenged) with chalazia require general anesthesia for either injection or incision and curettage. The same procedures and complications apply. 

Postprocedure Instructions

Instruct patients to call or return immediately if any change in vision, significant swelling, purulence, or excessive bleeding occurs. Reassure patients that a small amount of blood-tinged tearing and a mild foreign body sensation with blinking is normal (associated with incision and curettage). Patients often are more comfortable with a TID ophthalmic antibiotic following incision and curettage, although its use is not mandated. 

Coding Information and Supply Sources

Common ICD-9 Code

Chalazion 373.2 

Supplies

  • Chalazion forceps and curettes may be obtained from Katena Products, Inc., 4 Stewart Court, Denville, NJ 07834 USA (800-225-1195; http://www.katena.com).

  • Other instruments and supplies may be found in Appendix G.

Bibliography

Epstein GA, Putterman AM. Combined excision and drainage with intralesional corticosteroid injection in the treatment of chronic chalazia. Arch Opthalmol .  1988;106:514–516. [View Abstract]
Mannis MJ, Macsai MS, Huntley AC. Eye and Skin Disease . Philadelphia: Lippincott–Raven Publishers;  1996:644–647.
Ostler HB, Maibach HI, Hoke AW, et al. Diseases of the Eye and Skin—A Color Atlas . Philadelphia: Lippincott Williams & Wilkins;  2004:183, 196–197.
Vidaurri LJ, Pe’er J. Intralesional corticosteroid treatment of chalazia. Ann Ophthalmol .  1986;18:339–340. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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