Atlas of Primary Care Procedures, 1st Edition

Ear, Nose, and Throat Procedures

54

Chalazia Removal

Chalazia appear as chronic subcutaneous nodules of the eyelid. Chalazia develop from the obstruction of the meibomian gland duct at the eyelid margin. Leaking contents from an engorged, obstructed gland induce a lipogranulomatous (foreign body) reaction. The gelatinous contents within chalazia usually are sterile, although lesions can become secondarily infected.

Chalazia are frequently confused with hordeolums or styes. Hordeolums are acute, focal, inflammatory processes that manifest as suddenly appearing, erythematous, tender lumps in the eyelid. Hordeolums usually are self-limited, but internal hordeolums occasionally develop into chronic chalazia. Chalazia often appear in individuals with skin disorders such as seborrheic dermatitis or rosacea, and the coexisting blepharitis with these conditions can add to the diagnostic confusion with hordeolums.

Because chalazia may resolve spontaneously if the duct opens, some physicians advocate the application of warm compresses four times daily. Although one third of lesions may resolve over 3 months, a month of warm compress therapy is sufficient to identify those that will respond to conservative management. Chalazia present for more than a month generally require more aggressive management. One to three steroid injections have been shown to resolve many lesions within a few weeks time. A small intralesional injection of 0.05 to 0.2 mL of triamcinolone (5 mg/dL) can be administered from a tuberculin syringe. Depigmentation is not uncommon, especially in darkly pigmented individuals.

Long-standing chalazia often are managed with a simple office surgical procedure. Physicians can shield the eye during the procedure to promote safety and greater comfort for the patient and operator. The incision and curettage procedure is similar to other dermatologic procedures. Although success rates are high, there are recurrences, especially in individuals with predisposing skin conditions. Antibiotics are not necessary for postprocedure care, but the antiinflammatory effect of tetracycline and other antibiotics may prevent recurrence in individuals with rosacea or chronic blepharitis.

P.437

INDICATIONS

• Chronic nodules on the internal (conjunctival) or external (skin) portion of the eyelid
• Cosmetic concerns or chronic irritation from a chronic chalazion

RELATIVE CONTRAINDICATIONS

• Hordeolums (self-limited)
• Chalazia that have not undergone more conservative interventions (i.e., warm compresses)
• Known eyelid disease (e.g., sarcoid nodules, malignancy such as basal cell carcinoma)
• Injection in darkly pigmented individual

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PROCEDURE

Triamcinolone (0.05 to 0.2 mL of a 5 mg/mL concentration) is administered using a 30-gauge needle on a tuberculin syringe. When the chalazion is external, enter the lesion laterally with the needle directed away from the globe (Figure 1A). If the chalazion is internal, consider placement of a corneal eye shield (discussed later). The eyelid is everted for injection (Figure 1B).

PITFALL: Patients may suddenly move during any injection, endangering the eye. The supine patient's head should be stabilized against a firm surface, such as an examination table, with one or more assistants helping to steady the patient's head.

Proparacaine ophthalmic solution is liberally administered to the patient's affected eye.

P.439

A plastic corneal shield is lubricated with tobramycin ophthalmic ointment and then gently placed over the globe. A suction cup can be attached to the convex surface of the shield for insertion and removal (Figure 3A). Ask the patient to look down, and slide the upper edge under the upper lid (Figure 3B). As the patient looks up, the lower lid is grasped and elevated, and the lower portion of the shield placed beneath the lower lid (Figure 3C). The suction cup is removed.

P.440

Administer a small amount (0.1 to 0.4 mL) of 1% lidocaine without epinephrine in the skin surrounding the chalazion. Always angle the needle tip away from the globe as discussed earlier. If used, the chalazion forceps (clamp) can be applied at this point (Figure 4A). The flat portion of the clamp is placed against the skin, and the chalazion protrudes through the open ring (Figure 4B). The procedure can be performed without the clamp, using pressure from the fingers of the nondominant hand to stabilize the lesion and control bleeding.

P.441

A 2- to 3-mm incision is made into the chalazion with a no. 11 blade (Figure 5A). Place a 2-mm chalazion curette (“ice cream scoop”) into the chalazion cavity. Gelatinous material is extruded (Figure 5B) and wiped onto gauze. The walls of the chalazion are scraped vigorously in all directions, causing the chalazion to scar closed.

The chalazion curette and forceps (clamp) are removed. Any bleeding can usually be controlled with gentle pressure applied with gauze. After 5 minutes of pressure, the suction cup is applied to the corneal shield, and the shield gently removed. Saline eyewash can be applied, and a drop of antibiotic (e.g., gentamicin ophthalmic solution) applied. The patient is observed for 5 to 10 minutes and then released. No patching is necessary.

PITFALL: Sit the patient up slowly after the procedure. Observe for lightheadedness or a vasovagal reaction after lying flat for the procedure.

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CODING INFORMATION

INSTRUMENT AND MATERIALS ORDERING

Corneal eye shields protect the globe when performing eyelid surgery can be ordered from Ellman International, 1135 Railroad Avenue, Hewlett, NY 11557 (phone: 800-835-5355; http://www.ellman.com). Chalazion forceps (e.g., Desmarres, Ayer, Francis, Weis, Spencer; we prefer Heath 12 × 14 mm or Francis 12 × 14 mm) and chalazion curettes (e.g., Skeele, Meyhoeffer, Heath; we prefer a 5-inch [2- or 2.5-mm] Meyhoeffer) can be ordered from http://www.Surgical911.com, 13 West Main St., Suite A, Clinton, CT 06413, CT (http://www.surgical911.com).

Proparacaine hydrochloride (0.5%), gentamicin ophthalmic solution, and tobramycin ophthalmic ointment can be obtained from Falcon Pharmaceuticals, 6201 South Freeway, Ft. Worth, TX 76134 (http://www.falconpharma.com). Triamcinolone suspension can be ordered from Fujisawa Healthcare, 3 Parkway North, Deerfield, IL 60015 (http://www.fujisawa.com). A suggested anesthesia tray that can be used for this procedure is listed in Appendix G.

BIBLIOGRAPHY

Bedrossian EH. Treatment of hordeolums: styes and chalazia. Hosp Med 1997;33:59–64.

Black RL, Terry JE. Treatment of chalazia with intralesional triamcinolone injection. J Am Optom Assoc 1990;61:904–906.

Cottrell DG, Bosanquet RC, Fawcett IM. Chalazions: the frequency of spontaneous resolution [Letter]. Br Med J 1983;287:1595.

Diegel JT. Surgery for chalazion. In: Benjamin RB, ed. Atlas of outpatient and office surgery, 2nd ed. Philadelphia: Lea & Febiger, 1994:22–25.

Epstein GA, Putterman AM. Combined excision and drainage with intralesional corticosteroid injection in the treatment of chronic chalazia. Arch Opthalmol 1988;106:514–516.

Jackson TL, Beun L. A prospective study of cost, patient satisfaction, and outcome of treatment of chalazion by medical and nursing staff.Br J Ophthalmol 2000;84:782–785.

Lederman C, Miller M. Hordeola and chalazia. Pediatr Rev 1999;20:283–284.

Mustafa TA. Three methods of treatment of chalazia in children. Saudi Med J 2001;22:968–972.

Procope JA, Kidwell EDR. Delayed postoperative hemorrhage complicating chalazion surgery. J Natl Med Assoc 1994;86:865–866.

Reifler DM, Leder DR. Eyelid crease approach for chalazion excision. Ophthalmol Plast Reconstr Surg 1989;5:63–67.

Vidaurri LJ, Pe'er J. Intralesional corticosteroid treatment of chalazia. Ann Ophthalmol 1986;18:339–340.

Zuber TJ. Office procedures. The AAFP academy collection quick reference guides for family physicians. Baltimore: Williams & Wilkins, 1999:89–95.