oS { 38) Chalazion Removal: Incision and Curettage 1 Deseription/Indications. A chalazion is a lipo- granuloma of the eyelid that usually forms after a meibo- nian (tarsal) gland obstruction ruptures, releasing sebum into the surrounding tarsal tissue to incite a granulomatous reaction, oF following an acute internal hordeolom that fevolves into a chronic sterile granuloma. Chalazia are often fssociated with seborthea, chronic blepharitis, and acne rosacea, as well as Demodex infestation of the sebaceous iplands, Most chalazia are nontender, frm, slowly enlarging masses having Variable sequellae. This inflammatory tissue Teaction yields single or multiple lesions which ean cause pressure necrosis, issue swelling, discomfort, cosmetic dis- tress, and/or blurred vision. If standard treatment with hot compresses and topical andlor systemic antibiotics is unsuccessful lesional removal nay be indicated Patients frequently request removal, espe- {ally for cosmetic reasons. Inralesional injection of steroid (Gee p. 426) has been advocated by some practitioners, con sidered by many to be most suecessful if done during the arly stage of granuloma formation, Chalazia located close to the nasolacrimal system appear to be @ prime indication for steroid injection to avoid more invasive intervention near thecanaliculi. Incision and curettage or subconjunctival total txcision are the surgical methods of choice, initiated after any acute inflammation tas subsided. Both methods approach the lesion from the palpebral conjunctival side, ‘because the posterior tarsal plate containing the meibomian| lands is closest to this surface ofthe eyelid, and also 10 {void extemal skin scarring. Occasionally, granuloma for- tation ean extend through the skin surface or rupture and drain through the anterior id surface, requiring excision and ‘minimal suturing, 1 Instrumentation. 0.5% proparacaine ophthalmic ‘solution; 1 to 2% lidocaine with epinephrine 1:100,000 for injection: sterile: 18G 1 Y2-inch needle, 3 or Sl. syringe, 27 or 306 Yr-inch needle, chalazion clamp, chalazion carette, scalpel (eg. #11), toothed foreeps, scissors (€.8- Westcott or Stevens), gauze pads, eye pads, cotton-tipped applicators, latex. gloves; broad-spectrum antibiotic oph- thalmie ointment; I-inch micropore tape; specimen jar with formaldehyde; eye protection (optional); appropriate infee- tious waste disposal container; puncture resistant biohazard sharps container. 8 ue. Review the risks and benefits of the pro- cedure with the patient, and ask him or her to sign an ‘appropriate consent form. Prepare the syringe for injection with Tidocaine with epinephrine 1:100,000 for injection (Gee p. 402). For appropriate infection control, wear sterile latex gloves (see p. 475) and protective eye wear as indi- cated, Recline the patient to a flat, comfortable, secure supine position, Position proper illumination for the proce ure. Inform the patient of a brief pinching sensation, fol- Towed by mild buming associated with the anesthetic injection. Instill two drops of topical anesthetic into the eye. ‘Swab the area of the lesion using a sterile alcohol pad, ‘being careful not to allow any alcohol to drip into the eye, ‘and allow it to air dry, Using the 27 or 30G Y-inch needle, inject 0.5 to 1.0 mL of lidocaine with epinephrine subcuta neously (see p. 417) under the anterior lid skin surrounding, the elevated mass for initial infiltrative anesthesia (Fig. 1). ‘One or multiple injections may be necessary depending upon the size and location of the lesion, or simply angling the needle may amply extend the range of infiltration. Do not initially inject the lesion itself. Wait a few minutes for the anesthetic to work. Evert the involved lid (see p. 94), and apply a chalazion clamp by straddling both sides of the tyelid and centering the lesion in the opencd-ring side of the clamp (Fig. 2). Tighten the circular knob to secure the clamp and to achieve hemostasis. Allow the clamp to hang gently from the lid and rest on the forehcad or cheek away from the comea. If the brow is too prominent to rest the clamp on, position it so the handle is oriented horizontally toward the outer canthus. At this point, some practitioners inject the lesion itself subconjunctivally with anesthetic using the same syringe and keeping the needle anterior to the tarsal plate (Fig. 3) ‘Working from this exposed conjunctival side, make approximately a 3-mm vertical conjunctival incision through the length of the lesion withthe #11 blade, remain- {ng parallel to the meibomian glands (Fig. 4). Be careful not to cut any closer than 2 to 3 mm from the eyelid margin to prevent possible postprocedure lid notching. Some practi- toners reverse the blade, positioning the dull edge toward the lid margin, to help prevent unintentional margin dam age. Granulomatous chalazion material will often extrude through the edges of the incision.CHAIAZION REMOVAL: INCISION AND CURETIAGE «119 1, Injct he loca anethetc subeonscusly ot one oF more sts surround: Pare ed ing the cholozion fr inflirctive anesthesia, 2. Apply the chalazion clomp on elthr side ofthe everied eye: 3, Alter opplying the clamp and everting the ld, some practi id, centering the lesion i he opened ring. Tighten the circular Hone inject the cholazion ise with eneshetic solution. Keep nds, ond then ollow the clamp fo hang or rest way Fom the ‘he injection within the lsion, avoiding pasetation ino the ratotora ple arc. 4, Moke © 2'o 3:mm vetieel conjunctival inesion through the langth of the lesion with the 811 bled, remoining paral othe meibomion glands ‘and saying 2 to 3 mm away from the lid margin.120 EYEUD PROCEDURES Insert the curette into the newly created pocket open- ing and, using multidirectional movements, attempt to vig- ‘orously sweep all material out through the lesion incision (Fig, 5), Wipe material onto a sterile gauze pad between ccurettages. Use sterile cotton-tipped applicators to absorb any blood blocking your visibility of the incision area. If ‘additional drainage is needed, grasp the edge of the incision feo with sterile forceps and cut away a small elliptical 2¢ of the flap with sterile scissors (Fig. 6). Any residual Fibrous sae found, especially with long-standing chalazia, should be carefully removed if possible by grasping it with the forceps and cutting it away with the scissors, avoiding disruption of normal tissue. Place any material for biopsy into a properly labeled specimen jar. With superior lid gran- ‘ulomas, itis easier fo apply the clamp to the lid area first (Fig. 7A), and then evert the lid (Fig. 7B), recentering the lesion if necessary. Remove the clamp and apply direct pressure with ster- ile gauze to control any residual bleeding. Some practition- ‘ets lightly pinpoint cauterize the base of the operated area to control bleeding. Most battery operated high temperature disposable cautery units come in sterile packaged, loop tip ‘design with a safety cap (Fig, 8). Operate it by simply ‘depressing the side power button with the thumb as it is eld with a pencil grip. The tip glows brightly and quickly after the button is depressed, Contact time and the amount of tip surface contact determines the amount of thermal ‘energy applied to the treated area. For pinpoint cautery, momentarily touch the glowing tip to the desired area one for more times until the bleeding stops. Instill @ broad-spectrum ophthalmic antibiotic oint- ‘ment into the eye (see p. 12), and patch overnight or at least for a few hours (see p. 174). Prescribe warm com- presses and ophthalmic antibiotic ointment at bedtime or more often if desired for 1 week, informing the patient that some drainage may occur for a few days. Recommend nonaspirin analgesics for patients with any residual dis- comfort and schedule the patient for follow-up in 5 to 7 days. Dispose of soiled materials in an appropriate infec tious waste disposal container; dispose of the needle and syringe in a puncture-resistant biohazard sharps container. Ml Interpretation. Postprocedure lid edema, tender- ness, and redness are expected. Following incision and ccurettage of chalazion and with subsequent healing, the lid ‘will resume its normal appearance and the preprocedure signs and symptoms will resolve. Occasionally, a small granuloma detectable with lid palpation may remain, A ‘white, fibrous scar will develop on the palpebral conjunet- val side, noted on lid eversion. If pinpoint cautery is used, a small plume of smoke followed by small focal areas of eschar will appear as cau- terization is pecformed. ‘The diagnosis and treatment of recurrent chalazion in the same lid location, especially in the elderly, should be ‘made cautiously as sebaceous cell carcinoma can mimic chalazion, More extensive surgery may be required for recurrent chalazion, multiple lesions, or a poorly visualized chalazion sac. Subconjunctival total excision with biopsy is recommended for any suspicious lesion. With experience and confidence, consider a postproce- dure follow-up only if residual or new symptoms occur, or if the lesion recurs. In the event of the latter, fotal subcon- Jjunctival excision of the chalazion may be required. § Contraindications/Complications. Medical ‘contraindications to epinephrine should be noted in the pre~ procedure workup and avoided by using plain lidocaine for infiltrative anesthesia, especially in paticnts with heart dis- ease, hypertension and thyrotoxicosis. Any history of sensi- tivity to anesthetics, antibiotics, or analgesics should also be determined in the initial patient history. The topical anesthetic agents may produce local hypersensitivity reac- tions, including toxic keratitis ‘The major systemic side effects caused by local anes thetics are excitation of the central nervous system (CNS) and depression of the cardiovascular system. Initial CNS symptoms of anesthetic toxicity commonly include drowsi- ness, light-headedness, dizziness, and @ metallic taste fol- lowed by nausea, garrulousness, perioral numbness, tin- ling. diplopia, and tinnitus. The frst sign of cardiovascular toxicity is typically a reduction in blood pressure. Tremors, muscle twitching, seizures, loss of consciousness, respira- tory depression, and circulatory collapse have been reported. AS a result, when performing injections, it is important to ensure the prompt availablity of proper equip- rent and personnel trained to address medical emergencies, ranging from vasovagal syncope to cardiac arrest. Horizontal conjunctival-tarsal incisions should be avoided, as these frequently lead to scar tissue formation in ‘multiple meibomian ducis with subsequent gland blockage, rupture, and recurrent chalazia. Preprocedure evaluation for any accompanying cellulitis should always be performed, especially if erythema or pain is present, Systemic antibiotic treatment may be required to resolve the cellulitis before the lid procedare is scheduled. Excessive local anesthetic inf- tration should be avoided, as it can distort the tissue and rake the incision more difficult. Caution should be used with all injections, especially in dificult-to-each areas, to avoid perforation of the desired tissue and unintentional injection of another, as serous side effects can result.