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| ORIGINAL ARTICLE |
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| Year : 1992 | Volume
: 40
| Issue : 4 | Page : 103-105 |
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Subconjunctival total excision in the treatment of chronic chalazia
Somdutt Prasad, AK Gupta
Regional Institute of Ophthalmology, Medical College & Hospitals, Calcutta 700073, India
Correspondence Address:
Somdutt Prasad
Resident House Surgeon, Regional institute of Ophthalmology, Medical College & Hospitals, 88, College Street, Calcutta - 700 073
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 1300299 
A technique of subconjunctival total excision was used to treat 34 chronic chalazia. Another 34 were treated by incision and curettage and a further 32 by intralesional injection of long acting steroid. Subconjunctival total excision showed a higher success rate (94.12%) compared to the incision and curettage group (76.47%) and the injection group (75%). As the difference was statistically significant and due to other advantages we recommend subconjunctival total excision as a primary approach in the treatment of chronic chalazia.
How to cite this article:
Prasad S, Gupta A K. Subconjunctival total excision in the treatment of chronic chalazia. Indian J Ophthalmol 1992;40:103-5 |
| Introduction | |  |
A chalazion is believed to result from blockage of the meibomian duct orifice or stagnation of the meibomian gland secretions. Histopathology shows a peculiar inflammation of a meibomian gland producing granulation tissue rich in gland cells. The surrounding tissue of the tarsus becomes densely infiltrated with leucocytes ultimately resulting in a mass of granulations surrounded by a ring of fibrous tissue. Further evolution of this process leads to compression of peripheral tissue which now forms a dense capsule and retrogressive changes occur centrally [1].
Acute chalazia can be treated conservatively with warm compresses, meticulous eyelid hygiene together with topically applied antibiotics or antibiotic steroid medications [2],[3].
Chronic chalazia are usually treated by incision and curettage, others advocate intralesional injections of long acting steroids, some suggest conservative management over a six week period [3],[4],[5].
We believe that subconjunctival total excision offers a better alternative for treatment of chronic chalazia [6].
| Material and methods | | |
Over a period of one year (from November 1989 to October 1990) we treated 100 chalazia. 34 were treated by subconjunctival total excision (Group 1), another 34 by incision and curettage (Group II) and a further 32 by injection of steroid (Group III). The chalazia in this study were 3-7 mm in diameter. Patients with multiple small chalazia, infected chalazia and chalazia near the lacrimal system were excluded from this study. One case of presumed recurrence was eliminated from the study when histopathologic findings demonstrated a sebaceous gland carcinoma.
All cases were examined 2 weeks post-operatively. Patients were considered cured if there was no palpable or visible mass at this examination.
Local anaesthesia (infiltration with 2% lignocaine with adrenaline) was used, for subconjunctival total excision and for the incision and curettage groups.
Surgical Technique of Subconjunctival Total Excision (Group I)
A chalazion clamp was applied after infiltration with 2% lignocaine with adrenaline and the eyelid everted. A No. 15 Bard-Parker blade was used to make an incision perpendicular to the lid margin overlying the highest bulge of the chalazion. The incision stopped at least 4mm short of the lid margin.
Fine scissors were slipped under the conjunctiva on both sides of the incision to undermine and separate the underlying granuloma.
Undermined conjunctiva was then retracted sideways to expose the bulk of the chalazion. Resection of the chalazion was started at the end farthest from the lid margin. The chalazion was grasped with fine forceps and lifted. Fine scissors were used to undermine a plane between the chalazion and the orbicularis muscle. Dissection was carried out around the chalazion with the last excision being adjacent to the lid margin.
It was usually possible to remove the chalazion in one piece, but some had to be removed piecemeal. The process finished with the smooth surface of the orbicularis lining the floor of the wound and the firm white tarsus along the lateral edges. The conjunctiva was brushed back over the wound, the clamp removed and pressure applied to achieve haemostasis. The eye was then lightly patched after instillation of chloramphenicol eye ointment. The patch was removed after 12-24 hours.
Surgical Technique for Incision and Curettage (Group II)
Steps upto making the incision were identical to that in Group I. After making the incision the contents of the chalazion were vigorously curetted out. The clamp was removed and haemostasis achieved. Aftercare was similar to that in group 1.
Technique for Intralesional Injection (Group III)
Patients received one injection of triamcinolone acetonide 20 mg/ml, through the conjunctival aspect using a 26G needle. The average volume injected
| Statistical analysis | | |
A Chi-square test with one degree of freedom testing the null hypothesis of no association between type of procedure and cure rate was used to analyse the statistical significance in pairs of groups [7].
| Results | | |
Table one shows the results obtained. The results showed a 94.12% cure rate for patients in group I, compared to 76.47% in group II and 75.00% in group Ill. There were no recurrences in patients who had been cured by excision over a follow up period of 4-12 months. There was a statistically significant difference in favour of group I over group II(P 0.05) and in group I over group Ill (p. 0.05). Groups II and Ill did not show any significant difference in cure rates (p 0.50).
| Discussion | | |
Subconjunctival total excision offers the advantages of complete removal, while preserving conjunctiva. The lump is immediately gone and healing proceeds from a surgical incision rather than from a lump of absorbing residual granulomatous material as in incision and curettage. The excision technique appeared to produce less post-operative swelling and discomfort than incision and curettage. The excised tissue was available for histopathological examination. Although a small number (three) chalazia had to be removed piecemeal this did not seem to effect the results.
The defect in the tarsal plate healed by fibrous tissue formation with no deformity [1]. No eyelid malformation was observed in our series during follow up.
Epstein and Putterman in their series used an excision technique through a cruciate incision in the conjunctiva and excised the flaps so created. Corneal abrasions occurred in 2 of their patients [8]. We have not come across such a complication using our technique.
However the process is more time consuming and causes more anxiety and discomfort than an injection of steroid. The procedure may not be suitable for chalazia near the lacrimal system, for fear of damaging the canaliculi, and for patients with multiple small chalazia, as extensive dissection would be involved.
Triamcinolone injections offer a method which require minimal facilities and time, no patch is required and patient compliance is very good, with minimum pain bleeding and anxiety. There is no risk of damage to canaliculi and multiple chalazia may be injected in the same sitting if needed.
The reported success rates with injections vary widely and are as follows: Pizarello et al 88% (8 of 17 cases required 2 injections) [5]; Sloas et al 76% (16/21) [9]; Dua and Nilawar 93.3% (12% had 2 injections) [10]; Jacobs et al 8.7% (2/23 cured at 2 weeks) [11]. Jacobs et al further reported a 60% cure rate using incision and curettage.
In our series incision and curettage did not offer a significantly better result than steroid injections. No rise in intraocular tension, lid depigmentation, intraepidermal deposits of steroid or tissue atrophy was noted in our series of patients who received injections.
We have not compared our results with those of conservative treatment. Bohigian et al claimed that 50% chalazia could be cured in 1 month by conservative means [12]. Perry and Sernuik described a 76.6% rate of resolution within one month of medical treatment (warm compresses and lid hygiene) [3].
| Conclusion | | |
Subconjunctival total excision is a sure method for treatment of chalazia although intralesional steroid (triamcinolone) injection should be the initial therapy for multiple chalazia, those near the lacrimal system and overly apprehensive patients. We do not recommend incision and curettage. It would not be unreasonable to try a month of conservative therapy (warm compresses, lid hygiene and topical antibiotics) in view of the results reported by others, before proceeding to surgery.
| References | | |
| 1. | Duke Elder S, The ocular adnexa. In : System of Ophthalmology St.Louis, C V Mosby Co, 1974, Vol XIII, pp 242-247.  |
| 2. | Newell FW:Ophthalmology Principles and Concepts, edition 6, St.Louis, C V Mosby Co, 1986, pp 205-206. |
| 3. | Perry HD, Sernuik RA: Conservative treatment of chalazia, Ophthalmology, 1980; 87; pp 218-221. |
| 4. | Yassin JG, Minor oculopiastic surgery, In: Ophthalmic Plastic Surgery, Silver B(ed), edition 3, Rochester NY, American Academy of Ophthalmology and Otolaryngology, 1977, pp 63-65. |
| 5. | Pizarello LD, Jackobiec FA, et al, lntralesional corticosteroid therapy of chalazia, American Journal of Ophthalmology, 1978, 85, pp 818-821. |
| 6. | Christine LZ, Subconjunctival total excision of chalazia, In : Techniques in Ophthalmic Plastic Surgery. Ralph EW(ed), Wiley medical publication, 1986, pp 3-6. |
| 7. | Park J E, Park J, Health information and basic medical statistics, In: Textbook of Preventive and Social Medicine, Banarsidas Bhanot, Jabalpur, edition 12, 1989, pp 451-452. |
| 8. | Epstien GA, Putterman AM, Combined excision and drainage with intralesional corticosteroid injection in the treatment of chronic chalazia, Archives of Ophthalmology. 1988, 106, pp 514-516. |
| 9. | Sloas HA. Starling J et al, Treatment of chalazia with injected triamcinolone, Ann Ophthalmoi 1983, 15, pp 78-80. |
| 10. | Dua HS, Nilawar DV, Non surgical therapy of chalazion, American Journal of Ophthalmology 1983, 15, pp 78-80. |
| 11. | Jacobs PM, Thaller VT, Wong D, Intralesional corticosteroid therapy of chalazia: A comparison with incision and curettage Br. J, Ophthalmol 1984, 68, pp 836-837. |
| 12. | Bohigian GM, Chalazion: A clinical evaluation, Ann. Ophth 1979, 11, pp 1397-1398. |
[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1]
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