Chalazion Procedures

A chalazion is a chronic noninfective inflammation of the sebaceous glands of the eyelid that affects the meibomian glands in the tarsal plate. ^{[1, 2]} Clinically, it results in a painless, firm nodule of the eyelid. Marginal chalazia are caused by inflammation of the gland of Zeis located at the lid margin. They can affect both the upper and lower lids. ^{[1, 2]} Acne rosacea and posterior blepharitis commonly are associated with chalazion. Hyperimmunoglobulinemia E (Job syndrome) can be associated with aggressive chalazion.

Meibomitis predisposes to the formation of chalazion; the inflammation leads to blocking of the duct opening, resulting in clogging of the secretions and then swelling. ^{[1, 2]} This results in a chalazion and hardening of secretions with time. Chalazion is a noninfective condition. However, it can become infected and acutely inflamed, causing a tense, warm lid swelling called hordeolum internum. This is how meibomitis is linked to the pathogenesis of chalazion formation and recurrence.

On histological slides, it appears as deep dermal or subcutaneous suppurative lipogranulomatous inflammation containing neutrophils, plasma cells, lymphocytes, histiocytes, and giant cells in a zonal configuration around central lipid material. A pseudocapsule surrounds the cellular infiltrate. ^[3] Many chalazia resolve within 2 weeks of a topical antibiotic and steroid medication and application of warm compresses. ^[4] These aid in reducing inflammation and increasing the local blood supply.

Incision and curettage is a conventional and effective treatment of chalazion (see the image below). ^{[4, 5]}

Photograph of a left lower lid chalazion.

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In cases of multiple chalazia with no evidence of infection, local intralesional injection of triamcinolone may cause regression of the chalazion within a few weeks. ^[6] It also can be used as an alternative to standard surgical procedure. ^{[7, 8]}

Indications for chalazion procedures include the following ^[9] :

• A large chalazion

• A chalazion that does not respond to conservative management

• Multiple chalazia

• A chalazion causing significant astigmatic refractive error due to mechanical effects on the cornea ^{[10, 11]}

Inflamed chalazion (hordeolum internum) is an absolute contraindication.

Topical tetracaine is added to the eye and cul de sac, and 1-1.5 mL of lidocaine with 1:1,00,000 epinephrine are injected beneath the orbicularis muscle through the skin route over the chalazion site.

Equipment used in chalazion procedures includes the following:

• 30-gauge needle mounted on a 2-cc syringe loaded with anesthetic mixture as described.

• Chalazion clamp and scoop

• No. 15 Bard Parker blade/radiofrequency cautery tip with unit

• Vannas scissors (optional)

• Cotton-tipped applicators and dressing material.

• Single-tooth forceps

  Instrument tray (a: local anesthetic for infiltration, b: 30-gauge hypodermic needle, c: Bard Parker handle for blade, d: chalazion clamp, e: chalazion scoop, f: single-tooth forceps, g: Vannas scissors, h: radiofrequency tip).

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Supine position is preferred.

The technique is as follows:

• After adequate anesthesia, as described above, the skin is prepared and draped.

• A chalazion clamp is inserted so that its circular opening surrounds the conjunctival aspect of the chalazion while its other blade lies against the skin surface (see image below).

  Chalazion clamp is applied to the everted lower lid.

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• The clamp is tightened and used to evert and expose the conjunctival aspect of the eyelid. The clamp aid controls bleeding during the procedure and helps in fair localization of the lesion.

• No. 11 Bard-Parker blade or radiofrequency cautery tip in "cut/coag" or "hemo" mode is used to incise the tarsus vertically up to 3 mm over the area of the chalazion (see image below).

  Incision perpendicular to the lid margin is placed. Chalazion contents are seen popping out.

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• Care is taken to avoid inadvertent extension of incision to the lid margin.

• The curette enters the tarsal incision and scrapes the cyst, tarsus, and orbicularis surfaces until the entire contents and wall of the cyst are removed from the internal lid (see image below). The curetted material is always sent for histopathological examination to rule of malignancy because sebaceous gland carcinoma is known to present as a chalazion-like lesion.

  Contents of the cyst are being scooped with a chalazion scoop.

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• The wound is opened and inspected, and any remaining tags of tissue are picked up with the forceps and severed until the wound is free of any chalazion content or cyst wall (see image below). Meticulous excision of the entire cyst wall reduces the rate of recurrence. ^{[1, 9, 12]}

  Cyst is excised with radiofrequency cautery probe.

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• The clamp is removed and pressure is applied over the site until the bleeding is controlled.

• Clots are wiped from the wound with cotton-tipped applicators, and an antibiotic ointment is applied to the eyelids for 1 day.

• When the chalazion points externally, it may be removed through the cutaneous route. The procedure is essentially the same as that described for surgical treatment of chalazion by the internal route, but for the direct excision of the cyst and the skin incision. The skin incisions are performed parallel to the lid margin. Small incisions can be left unsutured. Gentle digital massage at the site 2 weeks after the procedure helps to smooth the scar surface and provides good cosmesis.

Pearls include the following:

• Avoid extension of incision to the lid margin.

• Exhibit additional precaution for medial eyelid chalazia to prevent inadvertent damage to punctum and canaliculi.

• Avoid dissecting deep beyond the tarsus to prevent full-thickness through-and-through cut.

• Remember to excise the cyst wall as much as possible.

Potential complications of chalazion procedures are as follows ^{[1, 9]} :

• Bleeding

• Lid notching due to incision to lid margin

• Tarsal plate instability due to too large incisions

• Recurrences

• Inadvertent ocular trauma

Local intralesional injection of triamcinolone may result in hypopigmentation at the site of injection, atrophy of the tarsal plate, visible depot of the medication, and/or a raise in intraocular pressure. ^[7]

Postoperatively, an antibiotic and steroid drop or ointment and lubricants are prescribed to the eye for 1 week. Initially, cold compresses are applied for 48 hours, and then warm compresses are continued several times a day. In cases of recurrent or multiple chalazia, a course of oral tetracyclines is prescribed for 1 month (doxycycline 100 mg twice a day for 1 week followed by 100 mg once a day for 3 weeks). A chalazion is usually a self-limiting condition with excellent prognosis. However, the patient is instructed to follow regular lid hygiene measures and control of meibomitis.

Prognosis

Prognosis is excellent.