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Chalazion Incision and Curettage

Intro

A chalazion is a lipogranulomatous inflammation of a meibomian gland in the eyelid that presents as a painless eyelid nodule or swelling. This pediatric patient presented with a chalazion that caused symptoms of eye irritation. The lesion had persisted for many months without improvement in response to warm compresses and eyelid scrubs with baby shampoo. Therefore, she underwent chalazion incision and curettage under sedation.

Methods

This video highlights the steps of chalazion incision and curettage. With a chalazion clamp tightened over the lesion, the eyelid is everted and an incision is made into the tarsus. A curette is used to scrape the walls of the cyst to remove the chalazion contents. At the conclusion of the procedure, the clamp is removed and pressure is applied to the area of the lesion for hemostasis.

Conclusion

Incision and curettage is a safe, relatively quick, and effective procedure for the management of persistent chalazia.

Authors

Michelle L. Huynh, BA

College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

Muhammad Shamim, MD  

Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

Christian Ponder, MD

Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

A. Paula Grigorian, MD

Arkansas Children’s Hospital – Department of Ophthalmology, Little Rock, Arkansas, USA

The procedure was performed at Arkansas Children’s Hospital, Little Rock, AR, USA.

Music by bensound.com.

A chalazion clamp is placed over the lesion and tightened. The eyelid is everted to expose the palpebral conjunctiva and tarsus. An incision is made into the tarsus at the previously marked location using a Bard-Parker size 15 surgical blade held in vertical orientation. A curette is used to scrape the walls of the cyst to remove the chalazion contents. A cotton swab is used to apply pressure for hemostasis. After the clamp is removed from the eyelid, more pressure is applied to the eyelid using the surgeon's finger pads to control bleeding.
Most chalazia resolve spontaneously in two to eight weeks. Warm compresses two to four times daily can help speed up the resolution. Incision and curettage is indicated when a small chalazion persists despite conservative management or is large enough to press on the eye and cause symptoms. More extensive excision may be indicated for larger chalazia.
An acutely inflamed chalazion, also known as a hordeolum internum, should not be incised.
The pediatric patient was placed in supine position in the procedure room. Sedation with propofol was administered. For young pediatric patients, sedation is necessary. Most older children and adult patients require only local anesthesia for the procedure. The skin was prepared in the usual ophthalmic fashion. A proparacaine hydrochloride ophthalmic solution USP 0.5% drop was administered to the procedural eye. The lesion was marked with a marking pen on the underside of the eyelid in order to make the initial incision in the proper place after lidocaine administration. 1% lidocaine with 1:100,000 epinephrine injection was administered underneath the orbicularis oculi muscle for local anesthesia.
A chalazion is diagnosed clinically and most commonly presents as a single painless upper eyelid nodule. However, patients can experience multiple simultaneous chalazia, tenderness if there is acute inflammation, and lesions on the lower eyelid. Patients usually present for evaluation when the chalazion has persisted for weeks to months. The history and physical exam should focus on ensuring that the presentation is characteristic of a chalazion and excluding other possible diagnoses, such as neoplasms, blepharitis, dacryocystitis, molluscum contagiosum, papillomas, and hordeolum. Symptoms that suggest a different diagnosis and may require further workup include acute visual changes, recurrent eye pain in the same location, fever, limited extraocular movements, and diffuse eyelid swelling.[1] Physical exam reveals a palpable, non-erythematous eyelid nodule less than 1 cm in size.[1] Incision and curettage of a chalazion is considered if the lesion has not resolved in response to conservative management, such as applying warm compresses for 15 minutes 2 to 4 times daily, lid massage, and cleaning with baby shampoo.[1]
The anterior lamella of the upper and lower eyelid is formed by the skin and orbicularis oculi muscle. The posterior lamella consists of the tarsal plate and underlying conjunctiva.[2] The meibomian glands are embedded within the tarsal plate. The anterior and posterior lamella are adjacent near the lash line. A deep chalazion is a benign sterile lipogranuloma resulting from inflammation of a tarsal meibomian gland.[3] A superficial chalazion is caused by inflammation of a Zeis gland, a sebaceous gland that opens into an eyelash follicle.[3]
Two procedural interventions for chalazia are intralesional triamcinolone acetonide (TA) injections and incision and curettage. Both procedures are effective treatments.[4,5,6] Incision and curettage is suitable for chalaza that are purulent, liquid, virally associated, atypical, or possible cases of masquerade syndrome. TA injections may be preferred for patients who do not tolerate local anesthesia, have multiple chalazia, or have lesions adjacent to the puncta, which could be damaged during surgery.[7] Incision and curettage is more invasive and time-consuming than TA injections. Advantages of incision and curettage compared to TA injections include less recurrence and quicker time to resolution.[4]
Complications from incision and curettage include minor bleeding and bruising at the lesion site. There can be small risks of lid notching from the incision and trauma to the tarsal plate and other structures near the incision site. Neomycin-polymixin B-dexamethasone (NeoPolyDex) ophthalmic ointment is applied three to four times daily for four days postoperatively to reduce swelling, redness, and irritation and to prevent infection.
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1. Jordan GA, Beier K. Chalazion. [Updated 2020 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499889/ 2. Patel BC, Lopez MJ, Joos ZP. Anatomy, Head and Neck, Eyelash. 2020 Jul 27. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. 3. Jordan GA, Beier K. Chalazion. [Updated 2020 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499889/ 4. Nabie R, Soleimani H, Nikniaz L, et al. A prospective randomized study comparing incision and curettage with injection of triamcinolone acetonide for chronic chalazia. J Curr Ophthalmol. 2019;31(3):323-326. Published 2019 May 7. doi:10.1016/j.joco.2019.04.001 5. Ben Simon GJ, Rosen N, Rosner M, Spierer A. Intralesional triamcinolone acetonide injection versus incision and curettage for primary chalazia: a prospective, randomized study. Am J Ophthalmol. 2011 Apr;151(4):714-718. 6. Goawalla A, Lee V. A prospective randomized treatment study comparing three treatment options for chalazia: triamcinolone acetonide injections, incision and curettage and treatment with hot compresses. Clin Exp Ophthalmol. 2007;35(8):706e712. 7. Ben Simon GJ, Huang L, Nakra T, Schwarcz RM, McCann JD, Goldberg RA. Intralesional triamcinolone acetonide injection for primary and recurrent chalazia: is it really effective? Ophthalmology. 2005 May;112(5):913-7.

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