Original Article
Comparison of Intralesional Kenacort Injection Versus Surgical
Intervention for Primary Chalazion
Narain
Das, Asma Shams, Beenish Khan, Muhammad Nasir Bhatti
Pak J Ophthalmol 2019, Vol. 35, No. 3
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See
end of article for authors
affiliations …..……………………….. Correspondence
to: Narain Das (ND) Assistant Professor SMBBMC Lyari, Karachi E-mail: narainpagarani@yahoo.com |
Purpose: To compare the efficacy and
safety of intralesional steroid injection versus surgical intervention
(Incision and Curettage) in Primary Chalazion. Study Design: Prospective, comparative and interventional hospital based study. Place
and Duration of Study: Shaheed Mohtarma Benazir Bhutto
Medical College Lyari and Sindh Government Lyari General Hospital, Karachi from
15th October, 2016 to 15th April, 2017. Material and Methods: All
patients diagnosed with chalazion on clinical basis from the Outpatient
department of Ophthalmology were included in the study. All patients were
randomly divided into two groups with 25 patients in each group. Group 1
received intralesional 0.2 ml triamcinolone acetonide while Group 2 received
surgical intervention (Incision and Curettage). Results: There were 50 eyes of 50
patients between the age group of 15 to 40 years and of either gender. Mean age was 25 ± 12.2 with male to female
ratio of 2:1. There were 19 (76%) patients who achieved complete resolution
of chalazion after intra-lesional triamcinolone acetonide in group I and there
were 21 (84%) patients out of 25 who achieved complete resolution of
chalazion after incision and curettage in group II. No ocular complication
such as bleeding, elevation of intra ocular pressure, eye lid de-pigmentation
or any loss of vision in either group was observed. Conclusion: Intralesional triamcinolone acetonide injection is nearly
as effective as surgical treatment (incision and curettage) in primary
chalazion. Keywords: Triamcinolone, Chalazion, Eyelid
Diseases. |
Chalazion is a chronic inflammatory Lipo-granulomatous
lesion of the eyelid1. It is the most common benign eyelid lesion
accounting for 13.4% of cases2. The site of pathology is the meibomian
gland, which lines the tarsus of the eyelid3. The most common
presentation is a painless lump or swelling on the upper or lower eyelid. The
condition may be unilateral or bilateral, external or internal and may consist of
single or multiple lesions2.
It can occur in individuals of all age groups but most commonly
presents in adults with 80% lesions occurring in individuals in the age group
of 11 to 30 years4. Although it can occur in any location of the
eyelid, most chalazia are found on the upper eyelid. This is because of the
concentrated anatomical distribution of Meibomian glands in the upper eyelid5.
An inflamed chalazion can be visualized through the tarsal conjunctiva upon
eversion of the eyelid. The lesion may take up the appearance of a whitish
granuloma with potential to rupture5. The most common symptoms
include swelling, redness and irritation. Swollen eyelids with a hard nodule
may also occur3. Larger lesions have a tendency to induce mechanical
ptosis and cause blurred vision due to astigmatism by pressing the cornea6.
Rarely, conjunctivitis and cellulitis may also occur5.
On histology, a chalazion is composed of
various inflammatory cells such as histiocytes, mononuclear lymphocytes, plasma
cells, polymorphonuclear cells and eosionphils7,8. Chalazia can also
occur with other eye conditions and can have inflammatory and viral causes.
Inflammatory causes include seborrheic dermatitis, acne rosacea and chronic
blepharitis. Viral conjunctivitis most commonly constitutes viral causes2.
Biopsy and microbiological analysis are needed to rule out neoplasms especially
in the elderly and in recurrent chalazion9. Neoplasms which may
mimic chalazia include sebaceous gland carcinoma, basal cell carcinoma,
squamous cell carcinoma or merkel cell carcinoma2.
A chalazion can be treated by medical
treatment as well as surgical interventions. The conservative treatment
involves warm compresses for 10 minutes four times daily, eyelid massage, lid
scrubs and mild topical steroids. Warm compresses help to open the glands, to
break and express the nodules. Antibiotics are only indicated in conditions
where the chalazion is associated with severe blepharitis or blepharitis
associated with rosacea. Tetracycline is used commonly. Alternative antibiotics
are azithromycin and erythromycin. Interventions include intralesional steroid
injection (ILSI) triamcinolone acetonide and incision and curettage2.
Injection of 0.05 to 0.3 ml of the steroid is given in the palpebral side using
the insulin syringe3.
Conservative management by warm compresses and antibiotics is
effective in up to 80% of cases while ILSI is found to be effective in 93% of
cases7,10,11. According to
the literature, steroid injection is an effective management for young patients
while incision and drainage is recommended for patients with multiple chalazia.
Combined treatment is recommended for patients with large, recurrent and multiple
chalazia12. For the past several years, a lot of research has been
conducted to compare the effectiveness of ILSI triamcinolone acetonide and
surgical intervention13. The literature reveals a mixed opinion and
no definite conclusion has been drawn yet. Secondly, very few studies have been
conducted in Pakistan to compare the effectiveness of steroid injection and
surgical management.
The primary goal
of our study was to compare the treatment outcomes and success of 0.2 ml
Triamcinolone injection and surgical intervention.
MATERIAL AND METHODS
The study was conducted at Shaheed Mohtarma Benazir Bhutto Medical
College Lyari and Sindh Government Lyari General Hospital, Karachi for duration
of six months from 15th October, 2016 to 15th April,
2017.
Fifty eyes of 50 patients between the age group of 15 to 40 years diagnosed
with primary chalazion on clinical basis of either gender were included in the
study from the outpatient department of Ophthalmology. Patients were selected
after taking ethical approval and informed consent. Patients having acute
infections and recurrent chalazion were excluded from the study. All patients
were randomly divided into two groups with 25 patients in each group. Group 1
received intralesional 0.2 ml (40 mg/ ml) triamcinolone acetonide while Group 2
received surgical intervention (Incision and Curettage).
Patients were briefed about the procedure, its benefits and
complications. Informed and written consent was taken from all the patients and
also advised for co-operation during the procedure. Slit lamp examination was
done before the procedure. Before starting the procedure in both the groups,
topical anesthesia (Proparacaine 0.5%) eye drops were instilled two to three
times in the affected eyes. After taking all aseptic measures, in group I
eyelid was everted and 0.2 ml (8 mg of 40 mg/ml) of triamcinolone acetonide
(injection kenacort) was injected trans-conjunctively in the center of the
lesion by using 26.5 gauge needles. In some patients when it was not possible
to evert the lid due to large swelling the same was injected transcutaneously.
Patching was done after putting betamethasone neomycin (Betnesol-N) eye
ointment for one to two hours. In group 2 lignocaine 2% with adrenaline one to
two ml was injected subcutaneously in the eyelid over the site of the
chalazion. Chalazion clamp was applied over the chalazion site and eyelid was everted,
then a small vertical incision was given with surgical blade no. 11. After that
curettage was done with chalazion currette. Pressure was applied for five
minutes to stop bleeding after removing the clamp. Patching was done for six
hours after putting Betnesol-N eye ointment.
Post operatively, tablet Augmentin 625 mg (500 mg amoxicillin and
125 mg clavulanic acid, Glaxo Smith Kline, UK) was given 3 times a day, Tablet
Denzen DS (Serratiopertidase 10 mg, Helix Pharma) was given 3 times a day,
Tablet Ibuprofen 400 mg (Brufen 400 mg, Mylan Products Limited) 3 times a day, Moxigan
eye drops 4 times a day (Moxifloxacin Hydrochloride, Barret Hodgson) and Betnesol-N
eye ointment (Betamethasone and Neomycin, Pharmaceutical AB) were advised for
one week.
The treatment outcomes were observed and
data was collected. Data analysis was done by using SPSS version 20.
Descriptive statistics was done and data was presented in the form of tables.
RESULTS
Out of 50
patients, majority consisted of males 32 (64%) and the rest were females 18 (36%).
The average age at the time of presentation was 25 ± 12.2
years. Half of the patients underwent surgical treatment (50%) while the other
half were treated with 0.2 ml triamcinolone injection (Table 1). The treatment
outcomes of both groups were compared. Patients treated with surgical
intervention had a better treatment outcome with 84% achieving complete recovery
compared to 76% of patients achieving complete resolution when treated with 0.2
ml triamcinolone (Table 2).
Table 1: General features and distribution of
patients.
Variables (n = 50) |
Mean ± SD/ n (%) |
|
Age |
25 ± 12.2 |
|
Gender |
Male |
32 (64%) |
Female |
18 (36%) |
|
Treatment |
Group 1 |
25 (50%) |
Group 2 |
25 (50%) |
Table 2: Outcomes of 0.2 ml triamcinolone and surgical
intervention.
Variable (n=50) |
Complete Resolution |
P-Value |
|
Yes |
No |
||
Group 1 |
19 (76%) |
6 (24%) |
0.480 |
Group 2 |
21 (84%) |
4 (16%) |
A total of 10 patients (20%) failed to
achieve resolution. Out of these, six were treated with ILSI and four were
treated with surgical intervention. Therefore, ILSI had a slightly greater risk
of failure in our study (Table 2).
DISCUSSION
Leinfelder first proposed the treatment
of chalazion by ILSI in 196414. Since then, many studies have been
conducted and have demonstrated surgery and ILSI to be equally effective4,15.
ILSI has proved to be an effective and
safe treatment for chalazia due to the fact that it is rarely associated with
serious complications. However, skin depigmentation remains a common side effect
in pigmented patients.16. Ho et al stated that 2 out of 56 patient
developed skin depigmentation in their study. However, in the Goawella study
none of the patients out of 56 developed this complication5.
Other rare side effects reported in
literature include yellow deposits at the site of injection12,
microembolism, rise in intraocular pressure17, and formation of
pyogenic granuloma7. The findings of the above studies are
contradictory to our study in which no side effects of the treatment modalities
were observed.
Although extremely effective, ILSI is
painful compared to injection of Triamcinolone into the subcutaneous tissue14.
The later causes less pain and does not require local anaesthetic. Therefore,
it can be considered as an alternative first line treatment14.
Surgical treatment of chalazion is a
minor surgical procedure used to treat complicated and recurrent lesions3.
Post-surgical cold compresses, maintenance of eyelid hygiene and avoidance of
contact lenses are essential measures to prevent infection18.
Several studies have been conducted to
compare the effectiveness of both these treatments. According to a study from
2014, two ILSIs were sufficient to produce complete resolution of multiple and
recurrent chalazia19. Similarly, according to Ben Simon et al most
cases resolved with an average of one to two ILSIs. Resolution was defined as a
decrease in size of 80% or more with no recurrence20.
CF Chung et al demonstrated a
statistically significant success rate of patients treated with conservative
management (58.3%) compared to those treated with ILSI (93.8%)14. TL
Jackson et al concluded that surgical treatment and ILSI both are equally
effective in eradicating three quarters of chalazia compared to one third
treated by conservative management21.
In the light of the above literature, it
can be concluded that both ILSI and surgical treatment are equally effective. The
findings of the above studies are consistent with our results in which we also
observed the near equal effectivity of the injection and surgical management.
However, Biuk D et al states a
significant difference in pain sensation experienced between the two groups.
Surgical treatment resulted in higher pain scores with a median score of 65.
In contrast, patients who received ILSI did not experience any pain (pain
score=0) thus producing higher rates of patient satisfaction.
Furthermore, patients treated by ILSI
needed less OPD visits, did not require antibiotics or analgesics or compressive
occlusion of the eye5. Therefore, ILSI is the treatment of choice in
children and when the chalazion is in close proximity to the lacrimal drainage
system to avoid surgical damage. Surgical treatment is preferred in cases of
infected chalazion, patients not responding to ILSI and patients with suspected
adeno-carcinomatous lesions in which histopathology is needed for confirmation
of diagnosis5.
It was also seen
that the response to treatment correlated with the size of the lesion as
demonstrated by a local study conducted by Tahir MZ et al15. The
authors found that the success rate of the treatment was greater in patients
presenting with lesions ranging between 2-6 mm (100%) compared to patients who
had lesions sized between 6-9 mm (97%)15. Similarly, another study
from 2017 highlighted that patients with lesions less than 5mm responded well
to treatment3. Furthermore, Lee J et al showed that there was no
significant difference between the treatment outcomes for adult and pediatric
patients undergoing treatment with ILSI.17.
CONCLUSION
Intralesional triamcinolone acetonide injection is nearly as effective as incision and
curettage in primary chalazion. It means it is a good alternative first line
treatment in cases where diagnosis is straight forward.
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Author’s Affiliation
Dr. Narain Das
(ND)
MBBS, FCPS (Ophthal)
Assistant
Professor
SMBBMC Lyari,
Karachi
Dr. Asma Shams
(AS)
MBBS, FCPS
(Ophthal)
Senior Registrar
SMBBMC Lyari,
Karachi
Dr. Beenish Khan
(BK)
MBBS, FCPS, FRCS (Ophthal)
Assistant Professor
United Medical & Dental College,
Karachi
Dr. Muhammad Nasir
Bhatti (MNB)
MBBS, FCPS
(Ophthal)
Professor, SMBBMC
Lyari, Karachi
Author’s Contribution
Dr. Narain Das
Data collection,
Performed all surgeries.
Dr. Asma Shams
Data Collection
and Statistical Analysis.
Dr. Beenish Khan
Manuscript
Writing and Language Correction.
Dr. Muhammad
Nasir Bhatti
Critical review.