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Chalazia are chronic lipogranulomatous inflammatory lesions resulting from the blockage of meibomian gland orifices by their complex oily secretions. Chalazia often present as painless nodules, but infected chalazia may result in preseptal cellulitis. Marginal chalazia are those located at the eyelid margin and usually result from superior extension (of a lower lid chalazion) beyond the lid margin or inferior extension (of an upper lid chalazion) beyond the lid margin.
Many treatment options exist in the literature regarding the general management of chalazia, but very little is published regarding the specific management of marginal chalazia. Marginal chalazia are frequently challenging to manage due to their location, and significant debate exists as to what constitutes best practice.
Case report
A patient in his early forties presented with a small painless chronic left lower lid margin lesion that had persisted for several months. There was no associated ulceration, telangiectasia, bleeding, tenderness or discharge. The patient described mild lower lid irritation and found the lesion cosmetically unattractive.
The clinical features were consistent with a lower lid margin chalazion.
Lower lid hygiene with bicarbonate of soda lid scrubs along with warm compresses was recommended. Oculentum hydrocortisone 2% was prescribed nocte. This management program, however, did not result in resolution of the marginal chalazion. Surgery was then performed, and this resulted in satisfactory functional and aesthetic results, evident both immediately and at 2 weeks following this procedure.
Questions
What different treatment options for marginal chalazia have been described in the literature? Why should curettage be performed?
Describe the technique of performing curettage on a marginal chalazion
What are potential side effects of surgery that you would need to advise the patient?
See page 596 for answers
(A) Curettage of left lower lid marginal chalazion with liberation of granuloma and pus; (B) curettage of left lower lid marginal chalazion demonstrating shallow defect visible at lid margin. Note total haemostasis and complete extirpation of the chalazion without removal of normal lid tissue (arrow). (C) Complete but not excessive extirpation of marginal chalazion at end of procedure, easily seen under total lid haemostasis (arrow).
Answers
From the questions on page 590
What different treatment options for marginal chalazia have been described in the literature? Why should curettage be performed?
Conservative measures
Hot compresses
Topical corticosteroids in ointment form
Invasive measures
The fact that there are so many different treatment options described in the literature suggests that not one treatment option is perfect. Conservative methods are associated with high failure and recurrence rates. Curettage, either alone or in combination with a corticosteroid injection, provides the best chance of rapid resolution and a low rate of recurrence while minimising the risk of adverse complications.
Describe the technique of performing curettage on a marginal chalazion
The surgical technique can be divided into the following steps. The specific technique of gentle curettage under complete haemostasis is demonstrated in figure 1. At definitive surgery, always done in the rooms/clinic in this study, the patient was operated using an opaque head drape with an eye aperture.
The surgeon first delineates the chalazion by its location, size and consistency.
Using a 30-gauge needle, the surgical site is infiltrated with a proprietary mixture of local anaesthetic and epinephrine.
Before definitive curettage, satisfactory anaesthesia is confirmed by testing for total lid margin insensitivity to pain by applying the injecting needle tip to the lid margin both nasally and temporally to the chalazion.
An appropriately sized chalazion clamp is then applied to the surgical site. It is orientated so that the more proximal chalazion can be operated immediately following completion of the marginal element. Complete haemostasis is ensured in order that the marginal lesion can be curetted with total precision. This eradicates the marginal element of the lesion without compromising normal lid margin tissue. This can generally only be done to near perfection when there is no blood oozing over the site of the intended curettage.
Under adequate magnification, the lesion is gently curetted in a nasal-to-temporal or temporal-to-nasal direction along the horizontal lid margin using a standard 2-mm chalazion curette. In the event that the chalazion were recurrent, an appropriate definitive biopsy should be considered to exclude sebaceous carcinoma.
The remainder of the chalazion more proximally in the lid is dealt with using the surgeon's usual technique. Care must be taken not to connect the main tarsal incision with the marginal defect created following curettage, since this could result in a lid notch which could possibly require later surgical repair.
In certain circumstances, particularly for chalazia that are chronic and well-organised, it may be necessary to inject depot steroid, notably with the chalazion clamp still in place. However, this is generally done only for the main tarsal element of the lesion.
All patients are reviewed after 1 month. If the chalazion has not resolved, the procedure is repeated and an appropriate biopsy taken.
What are potential side effects of surgery about which you would need to advise the patient?
Generally, over a total of 48 surgeon years using the above technique, we have observed very few complications resulting from treatment of marginal chalazia using this method. The patient should be advised that there is a small risk of the following complications:
Minor cosmetic scarring: A lid notch may result if the main tarsal incision is accidentally connected with the marginal defect created following curettage, and this may result in the need for future surgical repair.
Bleeding: this is usually minimal and is easily controlled with pressure.
Complications relating to associated steroid injection: If an injection of depot steroid is used, there is a theoretical risk of steroid embolisation resulting in anterior segment and/or retinochoroidal ischaemia.6–8 The risk of this potentially catastrophic outcome can essentially be eradicated if the chalazion clamp is left in situ until after completion of the injection.
Discussion
Multiple treatment modalities have been described in the general management of chalazia. These include conservative measures such as hot compresses or corticosteroid injections. Traditionally, surgical options such as incision and curettage, either alone or in combination with a corticosteroid injection, are usually performed. The choice of treatment may vary depending on the lesion's site, size, consistency and maturity.
There has been a recent resurgence of interest regarding corticosteroid injections as primary treatment for chalazia, but their utility as sole treatment of chronic organised granulomatous chalazia is limited. However, a combination of incision and drainage with intralesional steroid injection may be particularly useful in chronic non-marginal chalazia.9 Steroid injection after chronic chalazion surgery must always be administered with the chalazion clamp still in situ to maximise access of the steroid to any residual granuloma9 and to prevent the possibility of steroid embolisation with selected ocular ischaemia via anastomotic vessels.6 7 10
Marginal chalazia pose a particular challenge in management, since aggressive surgical management with incision and curettage may result in lid margin deformity. In this situation, several authors4 5 have suggested that local injections of corticosteroids may be helpful with marginal lesions as an alternative to surgery.
Historically, one of the treatments has been topical steroid ointment (oculentum hydrocortisone 2%). However, we have been disappointed with the results of this method and have also recognised the possibility of the risk of secondary glaucoma and cataract formation. The dilemma of therapeutic failure with this method was dramatically improved for the surgeons involved with this management once our technique of gentle lid margin curettage under excellent infiltrative anaesthesia and haemostasis was utilised.
The technique as described above is recommended. Long-term results suggest that lid remodelling occurs well and that the final outcome is that of an essentially normal lid. In addition to this excellent cosmetic outcome, curettage also minimises the risk of recurrence compared with the other treatment modalities.
Footnotes
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.