Introduction
Chalazion is a common chronic sterile lipogranulomatous mass in the eyelid that is caused by obstruction of the meibomian glands.1, 2 It is usually asymptomatic & is a non-sinister swelling. Although it can seldom cause mechanical ptosis, refractive errors due to induced astigmatism, amblyopia.2, 3, 4
Conservative treatments for chalazia are usually the first line treatments offered to patients & include warm compresses and antibiotic-steroid ointments. A combination of these methods usually have a reported success rate of around 25-50%. 3, 5
More invasive treatments for poorly responsive or non responsive pathology include intralesional triamcinolone acetonide (TA) and the incision & curettage (IC) procedure. 6, 7The complications most commonly encountered with triamcinolone acetonide injections are local skin depigmentation, skin atrophy, also in rare cases retinal & choroidal vascular occlusions, anterior segment ischemia and inadvertent globe injury. 8, 9, 10 With regards to incision & curettage, Bleeding, lid position abnormalities. Lid notching due to incision to the lid margin, tarsal plate instability due to large incisions were noted. Recurrences were noted in both procedures. 8, 9
Literature has suggested varying success rates, incidences of complications and recurrence rates with the procedures mentioned. Hence this study was performed to compare the outcomes of these two treatment methods in a South Indian cohort.
Materials and Methods
Inclusion criteria – Consenting patients attending the out-patient department of our hospital, a tertiary eye care institute in Bangalore, India who were subsequently diagnosed with a single chalazion occupying an eyelid in their eyelid/s during the period between October 2020 to December 2020 were enrolled for this study. This study was done keeping in mind the principles of good medical research and the Helsinki declaration. Patients were offered the choice between having intralesional triamcinolone or incision and curettage after explaining the risks, benefits & procedure of both these interventions and an informed written consent was taken. Each of these patients after the procedure were advised to continue hot fomentation & lubricant eyedrops post procedure.
Patients were excluded if they had chalazion that had atypical features, more than one chalazia per eyelid, concurrent eyelid infection, immunocompromised due to various causes and history of previous treatment with either of the 2 modalities being investigated. To avoid bias only chalazia between 4 – 8 mm were chosen in both treatment groups.
One surgeon (B.G) carried out all the TA injections and I&C’s. Post operatively the patient’s were assessed by one of our several senior optometrists who collected the data & also by Dr B.G.
Both groups of patients underwent ocular examination both before & after the procedure. The data collected included visual acuity, intraocular pressure, together with these the age, sex, duration, initial size & size on follow ups, recurrences if any. Two follow up visits were organised, one after 2 weeks and another being 3 months post-procedure.
A successful treatment outcome was considered when the chalazia reduced in size by 90% of the original.
Procedure of TA injections - the triamcinolone acetonide injection was performed under topical anaesthesia. An intralesional injection of 0.1ml TA with a concentration of 40mg/ml was administered intralesionally using a 26 gauge needle.
Procedure of I&C – the I&C were performed under local anaesthesia using lignocaine 2% with adrenaline. Under aseptic conditions, a chalazion clamp was inserted and a vertical incision was made on top of the affected site. The contents were scooped using a chalazion scoop. Hot compress used while releasing the clamp to secure quick haemostasis & facilitate evacuation of any granulomatous remnants. The patients were then sent home on a course of oral Amoxyclav as per their body weight.
Results
In total, 60 patients (22 male and 38 female) with chalazia were enrolled in this study. The TA group included 26 patients (13 male and 18 female), and the I&C group included 25 patients (9 male and 20 female). There was no statistically significant difference between sex distributions in the two groups (P = 0.28).
Table 1
Pre-operative demographic data
|
|
TA group |
I&C group |
P Value |
|
Number |
30 |
30 |
|
|
Mean Age ± SD |
18 ± 4.2 |
19 ± 3.4 |
0.28 |
|
Gender |
|
|
|
|
Male |
13 |
9 |
0.27 |
|
Female |
18 |
20 |
|
|
Size ± SD |
5.2 ± 2.8 |
5.2 ± 3.6 |
0.44 |
The mean age group of patients was between 12 & 26 years with a mean of 18 ± 4.2 in the TA group & 19 ± 3.4 in the I&C group. The age difference distribution in the 2 groups was not significant. The success rates were 80% (24 patients) and 96.67% (29 patients) in the TA & I&C groups respectively. Recurrences were seen in 9 patients in the TA group & 2 patients in the I&C group.
Among the treatment failures in both groups, the size of lesions was less than 50% of the initial size. These patients were then managed conservatively or with I&C as per size & clinical condition. In the TA groups, 6 patients who failed to resolve after the first injection of TA, responded completely to a second injection or I&C procedure. The patient with incomplete resolution following I&C opted for conservative management as she felt that the lesions were not cosmetically significant.
The initial sizes of the chalazia were between 4-8 mm, with a mean of 5.2mm. The mean initial size of the chalazia for the first & second groups was 5.2 ± 2.8 mm and 5.2 ± 3.6 mm, respectively. There was no statistically significant difference noted between the initial size of the chalazion & treatment success rates in both the groups.
46 (76.67%) chalazia were located on the upper lid & 14 (23.3%) chalazia were located on the lower lid. Chalazia location in the two groups did not have significant differences (P = 0.64). Chalazia location had no significant effect on the success rate either (P = 0.25 and P = 0.2 in TA and I&C, respectively). The visual acuity in both groups was unchanged when compared to the pre procedure levels.
The mean intraocular pressure which was measured with a rebound tonometer, on the pre operative visit was 16.69 ± 1.93 & on the 2nd post procedure visits was 16.49±1.08 mmHg and after 3 months was 16.15 ± 1.80 mmHg, respectively (P ~ 1).
There were no complications, except non resolution noted in either treatment group. In the TA group, 9 patients experienced a recurrence of the chalazia & 2 patients had a recurrence in the I&C group.
Discussion
In this study both intralesional TA injections & I&C were found to be effective treatment modalities for chalazia with success rates of 80% & 96.67% respectively. But the success rate of I&C was found to be higher than that of TA injections
Several publications have reported a success rate of around 50-95% for steroid injections. 3, 6 Some studies have shown that intralesional triamcinolone injections were as effective as I&C. 4, 11
Studies also describe that a single TA injection & eyelid massage post injection was as effective as I&C. 10
Other studies have reported clinical resolution after upto 3 intralesional TA injections regardless of the duration and consistency of the lesion. Literature also suggests I&C is the procedure of choice to treat chalazia of all types, but clinically TA injections could be offered to patients who refuse I&C due to various reasons, also in lesions near the canalicular system & lid margin. 12, 13
Another study reported that in small marginal chalazia, TA injections are of equal efficacy as compared to I&C. While large lesions had better responses to I&C. 14, 15 A study showed that older patients, with large lesions, and more chronic pathology were more likely to be responding to I&C, whereas in less chronic & smaller lesions equal success rates were noted in both TA & I&C groups. 16, 17
Our study shows that apart from the success rates, there is not much of a difference in terms of safety profile or risk of recurrence seen in both procedures respectively. This is similar in comparison to a majority of currently available literature.
Among the side effects reported with the use of intralesional TA, an increase in intraocular pressure & skin depigmentation are the most common. 15, 16 However in our study we did not encounter such occurrences. This might probably be due to genetics of the south Indian population who are naturally dark skinned, also there is not much literature available describing the incidence of steroid responders or any population specific data suggesting that the south Indian population is at a high risk of developing ocular hypertension.
Limitations of the study include a small sample size & a fixed time scale of review appointments making accurate monitoring of the speed of resolution less possible. To conclude, both TA injection and I&C are effective treatment modalities for chalazia. The advantages of I&C in comparison to TA include less recurrences and higher success rates.
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