Purpose
To compare treatment outcomes of intralesional triamcinolone acetonide (TA) injection with incision and curettage (I&C) for primary chalazia.
Design
Prospective, randomized clinical trial.
Methods
setting: Institutional. study population: Ninety-four patients with primary chalazia after failed conservative treatment were randomized to either intralesional TA injection (4 mg) or I&C performed under local anesthesia. All patients underwent comprehensive eye examinations that included digital photography of the lesion. Complete resolution was defined as lesion regression of 95% to 100%. Treatment was considered a failure if no resolution was achieved after the first attempted I&C or TA injection. main outcome measures: Lesion resolution measured as 95% to 100% regression.
Results
Ninety-four patients participated in the study: 42 underwent I&C and 52 underwent TA injection as the first treatment. Complete resolution was achieved in 33 (79%) of 42 patients in the I&C group and in 42 (81%) of 52 patients in the TA group ( P = .8, chi-square analysis). The average time to resolution in the TA group was 5 days, with most patients (48/52; 92%) having received a single injection and 4 (8%) of 52 patients having received 2 injections. TA precipitates were detected in 6 (11.5%) of 52 patients and resolved spontaneously. There were no complications, such as eyelid depigmentation, increased intraocular pressure, or any loss of vision, in either group.
Conclusions
Intralesional TA injection is as effective as I&C in primary chalazia. Injection may be considered as an alternative first-line treatment in cases where diagnosis is straightforward and no biopsy is required.
Chalazia are chronic lipogranulomatous inflammations of the eyelid caused by plugged meibomian glands. They may cause cosmetic disfigurement, local eye symptoms such as irritation and inflammation, and vision symptoms resulting from induced astigmatism or mechanical ptosis. Most lesions resolve spontaneously with warm compresses, local antibiotics, or steroid ointments. Treatment options for persistent lesions include incision and curettage (I&C), total excision, intralesional steroid injections, and botulinum neurotoxin type A injection.
Steroid injections can be applied either intralesionally or subcutaneously and are considered to be a simple and effective treatment with reported success and resolution in 50% to 95% of the cases. Intralesional or subcutaneous steroid injections result in successful treatment in 50% to 95% of cases. Adverse effects include eyelid depigmentation and, rarely, even vascular occlusion or anterior segment ischemia.
Several years ago, we found that triamcinolone acetonide (TA) results in regression in most patients after 1 to 2 injections, with few complications. Although I&C is considered a very effective treatment for chalazion, it is, nevertheless, minor surgery performed under local anesthesia. The purpose of this randomized, prospective study was to compare intralesional TA injection with I&C for primary chalazia.
Methods
This was a prospective study. All patients with primary chalazia who were attending the Orbital and Ophthalmic Plastic Clinic at the Goldschleger Eye Institute between September 2006 and September 2008 were invited to participate in the study. All patients had 1 chronic unilateral chalazia for at least 1 month (average, 5 months; range, 1 to 36 months) that failed to resolve after conservative treatment that included warm compresses, eyelid hygiene, and antibiotic and steroid ophthalmic ointments. They all had been referred from general ophthalmologist clinics in the community. Patients who agreed to enter the study signed an informed consent and were randomized to either intralesional 4 mg TA injection or I&C. All treatments and surgeries were performed by the same ophthalmologist (G.J.B.S.) in the outpatient procedure room on the same day they were examined. The study was approved by the local institutional review board. Randomization was performed according to clinic day: injections were performed on the first clinic day (Sunday, a regular working day in Israel), whereas I&C was performed on the alternate clinic day (Tuesday).
Lesions that failed to respond to a single treatment by TA injection were randomized again to either another injection or I&C. The patients whose lesions had failed to respond to 2 TA injections were recommended to undergo I&C. All patients who failed to respond to an initial I&C or TA injection were considered failures.
All study participants underwent an ophthalmic examination, including visual acuity (VA) and intraocular pressure (IOP) measurements. The patients were examined 1 and 2 weeks after treatment, or more often as required, for instance, in cases of partial resolution where additional treatment was required. All lesions were photographed before treatment and at each follow-up visit. Resolution was defined as lesion regression of 95% to 100% as assessed by clinical evaluation and digital photography. Most patients had complete clinical resolution, and only a few had some mild redness or swelling (less than 10% of the original size) at the first postoperative visit. Patients who had ever undergone prior surgical or injection treatment were excluded from the study.
Procedures
Triamcinolone Acetonide Injection
Topical anesthesia eye drops were instilled and 0.1 mL TA 40 mg/mL was injected intralesionally using a 25-gauge needle. When possible, the eyelid was everted and the injection was performed to the tarsal plate. Otherwise, injections were performed transcutaneously. The eye was left unpatched.
Incision and Curettage
The eyelid was infiltrated with 2 to 3 mL lidocaine 2%. Topical Betadine solution 5% (Iodine 5%; Vitamed Ltd., Binyamina, Israel) was used to prepare the eyelid, and the procedure was performed under sterile conditions in the outpatient procedure room. The eyelid was everted using a chalazion clamp. A single vertical incision was made at the point of the lesion, all pus material was cleaned by means of a curette, and the lesion’s capsule was incised and removed. The eye was bandaged for 2 hours with an eye patch after steroid ointment had been applied. The patient was instructed to remove the patch 2 hours later.
Statistical Analysis
The paired-samples t test was used to evaluate preinjection and postinjection data, such as VA and IOP. Pearson bivariate correlation was used to examine the influence of age, duration of chalazion, number of injections, and time to resolution. An independent samples t test was used to evaluate differences in gender and the presence of blepharitis on clinical outcome (steroids response and time to resolution). The chi-square cross-tabs test was used to examine the success of treatment (a lesion regression of more than 95%) between the 2 groups. For comparison of success, the statistical evaluation was performed as if no repeat treatment had been applied, that is, considering the lack of response to either method after the first attempt as representing treatment failure. Statistical analysis was carried out using Microsoft Excel 2003 (Microsoft Corporation, Redmond, Washington, USA) and SPSS software version 13.0 (SPSS, Inc, Chicago, Illinois, USA).
Results
Ninety-four patients with primary chalazia participated in the study. Forty-two patients underwent primary I&C, whereas 52 patients underwent intralesional TA injection. The patients in both study groups were similar in gender, duration of lesion, and lesion location. Patients in the TA group were significantly older than those in the I&C group (38 years vs 32 years; P = .04, independent-samples t test). In addition, the TA patients had a longer follow-up time (1.4 months compared with 0.7 months in the I&C group; P = .04). The demographics of the entire study population are summarized in the Table .
| Incision and Curettage | TA | P Value | |
|---|---|---|---|
| No. | 42 | 52 | |
| Age (±SD), yrs | 32 (±14) | 38 (±15) | .04 a |
| Gender | |||
| Male | 25 | 23 | .14 (NS) b |
| Female | 17 | 29 | |
| Duration (±SD), mos | 6.1 (±6) | 4.6 (±3) | .14 (NS) a |
| Location | |||
| RUL | 15 | 18 | |
| RLL | 8 | 9 | .97 (NS) b |
| LUL | 11 | 13 | |
| LLL | 8 | 12 | |
| Follow-up (mos) | 0.7 (±0.7) | 1.4 (±2.0) | .04 a |
Success was achieved in 33 (79%) of 42 patients in the I&C group and in 42 (81%) of 52 patients in the TA group. This difference was not significant ( P = .8, chi-square analysis). Figure 1 shows lesion resolution after TA injection, and Figure 2 shows a similar resolution in a different patient 2 weeks after TA injection.
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