Lid Lesions
Alice A. Lin, MD
PEDIATRIC LID LESIONS
Preoperative Considerations
One of the main preoperative considerations with pediatric lid lesions is whether there is need for surgical treatment at all. Many lid lesions will get better with time and nonsurgical treatments. Given most caregivers’ aversion to surgery and general anesthesia for their child, try to maximize all nonsurgical options first.
Many lesions may also be treated under local anesthesia. The ability to safely remove a lid lesion without sedation depends on the individual patient. Children and even some teenagers often will not be able to tolerate the procedure without sedation due to anxiety and stress.
If performing the procedure with local anesthesia in the clinic setting, place 1 drop of topical anesthetic in the eye on the affected side so the patient will not experience stinging from the Betadine prep. Then, slowly inject 2% lidocaine with epinephrine around the affected area. Use a 27G to 30G needle on a 3- or 5-cc syringe. The local injection requires time (˜5-8 minutes) for the lidocaine to induce anesthesia and for the epinephrine to induce vasoconstriction.
When the patient is under general anesthesia, a local anesthetic with epinephrine should still be used. If used early, the local anesthetic can control bleeding but can sometimes make it more difficult to localize a small lesion. Consider using a marking pen to delineate lesions prior to injection of local anesthetic. Be careful not to remove marks during the sterile prep. Alternatively, the anesthetic can be injected at the end of the case to provide postoperative hemostasis and anesthesia.
CHALAZION
Preoperative Considerations
There are many options for treating acute chalazia that span from over-the-counter (OTC) or home-based treatments to surgical interventions. Chronic and recurrent chalazia are increasingly felt to be related to a Demodex infestation/overgrowth1 so long-term treatment is aimed at decreasing the mite burden around the eyelids and eyelashes.
Home-based treatments include frequent warm compresses and eyelid scrubs. Blepharitis and chalazia may respond to daily eyelid scrubs with baby shampoo. Other non-prescription options include tea tree oil scrubs and OTC hypochlorous acid sprays. A daily dose of 500-1500 mg of a good-quality omega-3 supplement can be added to address meibomian gland dysfunction.
Prescribed medical treatments may include topical antibiotic/steroid drops or ointment, topical azithromycin (Azasite), and oral antibiotics such as oral azithromycin, erythromycin, or doxycycline (over 8 years of age only). LipiFlow or MiBiFlow treatments can also be administered in the office in some cooperative children.
Surgical interventions include Kenalog injections as well as incision and drainage of chalazia. Depending on the patient, these procedures can be performed in the office under local anesthesia or in the operating room under general anesthesia.
Surgical Planning
Manage patient and caregiver expectations. Warn caregivers that the incision and drainage of chalazia only treats the current lesion(s) and does not prevent future chalazia from forming.
Consider consent for treatment of both eyes or all four eyelids if the patient is under general anesthesia. Perform a thorough examination under anesthesia and drain any chalazia present. The 67808 CPT code includes the incision and drainage under anesthesia of multiple chalazia on multiple eyelids.
If a chalazion is external, excise the chalazion externally and remove all affected skin. Warn caregivers that they will see an open wound or defect in the eyelid but that this typically heals well with minimal scarring.
Surgical instruments:
a Bard Parker no. 11 blade or a no. 15-degree stab blade, chalazion lid clamp, chalazion curettes, sterile cotton tipped applicators, 4 × 4 gauze pads, 2% lidocaine with epinephrine on a 27G needle, a 1- or 3-cc syringe, triamcinolone acetonide (Kenalog) (10, 20, or 40 mg/mL), fine toothed forceps, Westcott scissors.
Surgical Procedure
Inject local anesthesia with epinephrine (see Chapter 1) around each chalazion if desired. Consider marking small chalazia with a permanent marker prior to injection.
Clean and prep each affected eyelid with Betadine prep.
Center and apply chalazion clamp to affected area. In most cases, it is preferable to evert the eyelid and incise the tarsal conjunctiva. However, external chalazia should be addressed externally, with all affected skin removed.
For intralesional steroid injections, draw up 0.1-0.2 cc of the steroid and inject the affected area using a 27G needle, either transcutaneously or transconjunctivally.
May repeat in 2 weeks if not resolved.
Consider using triamcinolone acetonide 10 or 20 mg/mL or injecting transconjunctivally in patients with pigmented skin because of the risk of skin depigmentation.
Be aware that any intralesional injection carries the risk of vision loss due to a steroid embolus causing a central retinal artery occlusion (CRAO).
Surgical incision and drainage:
Internal chalazion—make a vertical incision over the center of the chalazion with a sharp blade. Take care not to extend the incision to the lid margin to avoid creating a notch. Express the contents using sterile cotton tipped applicators and a curette. Use a curette to ensure that there are no further pockets that need to be cleared. If there is fibrotic scar tissue, consider using triamcinolone acetonide
to augment the treatment. 0.1-0.2 cc of triamcinolone acetonide can be dripped over the area or injected around the cavity. Any steroid injection carries the risk of CRAO, skin depigmentation, and fat atrophy.
External chalazion—often, the pressure from the chalazion lid clamp itself will rupture the scab, opening the cavity. If it does not, use toothed forceps and Westcott scissors to remove the scab, then clear the cavity using cotton tipped applicators and a curette. All affected skin should be removed to heal effectively. Use low temp cautery as needed for hemostasis. Leave the wound open to heal by secondary intention.
Postoperative Considerations
Apply antibiotic-steroid ointment to the affected area.
If desired, apply a pressure eye patch; to promote hemostasis, reduce edema and prevent children from rubbing the area as they awaken from anesthesia. The patch can be removed after a few hours.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
