Intralesional Triamcinolone Acetonide Injection Versus Incision and Curettage for Primary Chalazia: A Prospective, Randomized Study

GUY J. BEN SIMON, NACHUM ROSEN, MORDECHAI ROSNER, AND ABRAHAM SPIERER 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 dened as lesion regression of 95% to 100%. Treatment was considered a failure if no resolution was achieved after the rst 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 rst 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 rst-line treatment in cases where diagnosis is straightforward and no biopsy is required. (Am J Ophthalmol 2011;151:714 718. 2011 by Elsevier Inc. All rights reserved.)
PURPOSE:

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.19 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.10 13 Several years ago, we found that triamcinolone acetonide (TA) results in regression in most patients after 1 to 2 injections, with few complications.3 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

C
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HALAZIA ARE CHRONIC LIPOGRANULOMATOUS IN-

ammations of the eyelid caused by plugged meibomian glands.1,2 They may cause cosmetic disgurement, local eye symptoms such as irritation and inammation, and vision symptoms resulting from induced

Accepted for publication Oct 15, 2010. From the Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel (G.J.B.S., N.R., M.R., A.S.). Inquiries to Guy J. Ben Simon, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel; e-mail: guybensimon@gmail.com

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 rst clinic day (Sunday,
RIGHTS RESERVED. 0002-9394/$36.00 doi:10.1016/j.ajo.2010.10.026

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TABLE. Demographics of 94 Patients with Primary Chalazia Treated Either by Incision and Curettage (42 Patients) or Intralesional Triamcinolone Acetonide Injections at the Goldschleger Eye Institute between September 2006 and September 2008
Incision and Curettage

TA

P Value

No. Age ( SD), yrs Gender Male Female Duration ( SD), mos Location RUL RLL LUL LLL Follow-up (mos)

42 32 ( 14) 25 17 6.1 ( 6) 15 8 11 8 0.7 ( 0.7)

52 38 ( 15) 23 29 4.6 ( 3) 18 9 13 12 1.4 ( 2.0)

.04a .14 (NS)b .14 (NS)a

FIGURE 1. Right lower eyelid chalazion (Left) before and (Right) 1 week after an intralesional triamcinolone injection (4 mg). Note complete resolution of the lesion by 1 week later (Right).

.97 (NS)b

.04a

LLL left lower eyelid; LUL left upper eyelid; NS not signicant; RLL right lower eyelid; RUL right upper eyelid; SD standard deviation; TA triamcinolone acetonide. a Independent samples t test. b Chi-square (cross-tab) analysis.

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 dened as lesion regression of 95% to 100% as assessed by clinical evaluation and digital photography.3 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 rst postoperative visit. Patients who had ever undergone prior surgical or injection treatment were excluded from the study.
PROCEDURES:

FIGURE 2. Left lower eyelid chalazion (Left) before and (Right) 2 weeks after a single injection of triamcinolone acetonide (TA) injection (4 mg). Note that small TA precipitates followed the injections: this resolved spontaneously within a few weeks.

Incision and Curettage. The eyelid was inltrated 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 lesions 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:

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. THERAPEUTIC APPROACHES

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 inuence 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 PRIMARY CHALAZIA 715

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FIGURE 3. Left upper eyelid chalazion (Top left) before, (Top right) 1 week after triamcinolone acetonide (TA) injection, and (Bottom left) 5 weeks after TA injection. Note that the lesion remained unchanged, as did small precipitates of TA. (Bottom right) The lesion underwent incision and curettage with complete resolution.

FIGURE 4. (Top) Left upper eyelid chalazion with only partial resolution at 1 week after incision and curettage and (Bottom) complete resolution after an injection of triamcinolone acetonide.

method after the rst 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 PARTIC-

ipated 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 signicantly older than those in the I&C group (38 years vs 32 years; P .04, independentsamples 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. 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 signicant (P .8, chisquare 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. The average time to resolution was 5 days in the TA group, with most of the patients (48/52; 92%) having received a single injection, and the remaining patients (4/52; 8%) having received 2 injections. All patients who failed to respond to a single injection did not have complete resolution after the second injection, either. The patients who failed to respond to TA injections were older than the patients who showed complete resolution (52 14 vs 35 13 years, respectively; P .001, independent samples t test). This difference in age was not apparent in 716 AMERICAN JOURNAL
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the I&C group. TA precipitates (Figure 2, Right) were detected in 6 (11.5%) of 52 patients, and they resolved spontaneously within a few weeks with no need for additional surgical intervention. The average time to resolution was 4 days in the I&C group; this was not different from the TA group (P .37, independentsamples t test). 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 failed to respond to 2 TA injections were recommended to undergo I&C (Figure 3). The few lesions that failed to regress after I&C showed complete resolution after a rst or second TA injection (Figure 4). All patients who failed to respond to an initial I&C treatment or TA injection were considered failures. VA and IOP remained unchanged after both treatment approaches. The average VA was 20/20 before and after treatment in both groups, and the average IOP changed from 14.6 to 15.4 mm Hg in the I&C group and from 13.0 to 14.5 mm Hg in the TA group (not signicant). We did not encounter any complications in the TA group, such as loss of vision, increased IOP, or eyelid depigmentation. Similarly, there were no complications, such as delayed bleeding, in the I&C group.

DISCUSSION
THE RESULTS OF OUR PREVIOUS STUDY SHOWED THAT TA

injections were effective in lesion regression, but that study had been a retrospective and noncomparative investigation.3 The current work was designed to compare prospectively the efcacy of steroid injections with I&C in OPHTHALMOLOGY APRIL
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primary chalazia. We conrmed that intralesional TA injection was effective, and we also found it to be as effective as I&C for the successful treatment of primary chalazia. Most lesions resolved with 1 injection, and only a few required 2 injections. Moreover, TA injection could be applied successfully after a failed I&C. TA precipitates occurred in 11% of the cases, but they resolved spontaneously without the need for surgical intervention. In both our prior and current studies, most patients did not need more than a single TA injection.3 Because we considered that patients who failed to respond to 2 injections were more likely not to have a favorable response to additional ones, the protocol that we followed was that the patients who failed to respond to 2 injections were to be advised to undergo I&C. This study supports our earlier conclusion that TA injection(s) may be a good alternative to I&C in primary chalazia when diagnosis is straightforward and no biopsy is required. Treatment by injection is simpler and less inconvenient to the patients, although the eyelid injection may be somewhat painful. Previous studies evaluated the efcacy of steroid injections in chalazia.4 9 Goawalaa and associates compared intralesional TA 2 mg with I&C and warm compresses and found similar resolution rates for TA and I&C (84% and 87%, respectively) that were signicantly higher than conservative treatment only (46%).4 Interestingly, their TA patients reported less pain and less inconvenience associated with the procedure in comparison with surgical treatment. We had a similar resolution of approximately 80% in both groups, and so our conclusions that a single TA injection may be as effective as I&C in eyelid chalazia and that it is more tolerable by patients are similar to their conclusions. The only difference was that their treatment outcome was assessed by self-reporting via a telephone interview at 3 weeks after treatment and ours was by clinical examination with digital photography. Interesting works by Dhaliwal and Bhatia and Dhaliwal and associates aimed to investigate possible correlations between lesion histologic analysis and treatment outcome after either I&C or intralesional steroid injections.6,14 All of their patients underwent ne-needle aspiration cytologic analysis followed by either treatment arm. They found that older patients, lesions of longer duration, and lesions that were larger were more likely to be suppurating granulomas, and that this histologic type responded better to I&C. Their experience was that mixed-cell granulomas responded equally well to both therapeutic methods. Our study patients in the TA group were signicantly older than those in the I&C group; however, they achieved a similar success rate. In contrast, the patients who failed to respond to TA injections were signicantly older than those who showed lesion regression after TA injection (52 years vs 35 years; P .01). Taken together with the ndings of Dhaliwal and Bhatia and of Dhaliwal and associates, these results may imply that older patients may benet more from I&C, rather than from TA injection, VOL. 151, NO. 4 THERAPEUTIC APPROACHES

although the cutoff age remains to be determined.6,14 Unfortunately, we did not measure lesion size in relation to treatment outcome, as they did. We reason, however, that larger suppurating lesions may respond better to treatment by surgery than to injections. Importantly, several investigators advocated surgical treatment, even in the form of total excision, over I&C or steroid injections in the treatment of chronic chalazia.9 Khurana and associates stated that intralesional therapy is equally effective in small, multiple, and marginal chalazia, whereas larger suppurating lesions may respond better to surgery than to injections.7 Other investigators reported good response to steroid injections in up to 92% of the cases, regardless of the duration or consistency of the chalazion.8 The most serious adverse effect of intralesional steroid injection is vascular occlusion with loss of vision. This has been described after intralesional depot steroid injections10 and after intralesional steroid injections for periocular juvenile hemangioma.15 In the latter condition, the authors believe that forced injection or digital massage caused retrograde arterial ow that moved steroid suspension particles into the central retinal artery.15 Retinal and choroidal vascular occlusion also has been described after posterior sub-Tenon TA injection for treatment of uveitic macular edema.16 A similar complication occurred after intranasal injection of TA in a 22-year-old woman with chronic sinusitis,17 probably as a result of inadvertent intra-arterial injection into the anterior or the posterior ethmoidal artery, with retrograde ow into the ophthalmic arterial system. We did not encounter any similar complication in either the current study or in our previous work, nor did we nd any report in the literature describing vascular occlusion after intralesional TA injection for chalazia.3 It may be that the small volume of injection (0.1 mL) and the location of the lesion on the eyelid carry a very low risk of embolization and vascular occlusion. Nevertheless, before treatment, our patients were always told that loss of vision secondary to periocular steroid injection is a rare but possible complication of the procedure. Depigmentation is a rare complication that may occur after local injection of TA. Localized depigmentation may have important cultural implications for dark-skinned patients. Less-potent and shorter-acting steroid preparations have a lower likelihood for depigmenting side effects, and such agents may be more appropriate when injecting subcutaneous structures to prevent this complication.18 All patients in the current study were white, and this complication did not develop in any of them after TA injection. In summary, ours and several previous reports support intralesional steroid injections for the treatment of eyelid chalazia. We believe that TA injection should be offered to all patients when biopsy is not required. If treatment by 1 or 2 injections fails, then I&C should be recommended. TA injections may be more benecial in marginal or
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multiple chalazia or in those located near the lacrimal puncta by avoiding excess scarring with the resultant cosmetic or functional disturbances. Further comparative

studies are required to evaluate the inuence of lesion size, consistency, and eyelid location on the choice of rst-line treatment by surgery or injection.

PUBLICATION OF THIS ARTICLE WAS SUPPORTED IN PART BY THE TALPIOT MEDICAL LEADERSHIP PROGRAM, SHEBA MEDICAL Center, Tel Hashomer, Israel. The authors have no proprietary or commercial interest in any materials discussed in this article. Involved in Design of study (G.J.B.S., A.S.); Conduct of study (G.J.B.S.); Collection of data (G.J.B.S., M.R., N.R.); Management (G.J.B.S., A.S.), analysis (G.J.B.S., M.R., N.R., A.S.), and interpretation (G.J.B.S., N.R., A.S.) of data; and Preparation (G.J.B.S.), review (G.J.B.S., N.R., M.R., A.S.), and approval (G.J.B.S., N.R., M.R., A.S.) of manuscript. This study was approved by the Helsinki Committee Sheba Medical Center, Tel Hashomer, Israel. The authors thank Esther Eshkoli for professional English editing.

REFERENCES
1. Dua HS ND. Nonsurgical therapy of chalazion. Am J Ophthalmol 1982;94(3):424 425. 2. Perry HD SR. Conservative treatment of chalazia. Ophthalmology 1980;87(3):218 221. 3. Ben Simon GJ, Huang L, Nakra T, et al. Intralesional triamcinolone acetonide injection for primary and recurrent chalazia: is it really effective? Ophthalmology 2005;112(5): 913917. 4. Goawalla A, Lee V. A prospective randomized treatment study comparing three treatment options for chalazia: triamcinolone acetonide injections, incision and curettage and treatment with hot compresses. Clin Exp Ophthalmol 2007; 35(8):706 712. 5. Pizarello LD JF, Hofeldt AJ, Podolsky MM, Silvers DN. Intralesional corticosteroid therapy of chalazia. Am J Ophthalmol 1978;85(6):818 821. 6. Dhaliwal U, Bhatia A. A rationale for therapeutic decisionmaking in chalazia. Orbit 2005;24(4):227230. 7. Khurana AK, Ahluwalia BK, Rajan C. Chalazion therapy. Intralesional steroids versus incision and curettage. Acta Ophthalmol (Copenh) 1988;66(3):352354. 8. Mohan K, Dhir SP, Munjal VP, Jain IS. The use of intralesional steroids in the treatment of chalazion. Ann Ophthalmol 1986;18(4):158 160. 9. Prasad S GA. Subconjunctival total excision in the treatment of chronic chalazia. Indian J Ophthalmol 1992;40(4): 103105.

10. Yagci A PM, Egrilmez S, Sahbazov C, Ozbek SS. Anterior segment ischemia and retinochoroidal vascular occlusion after intralesional steroid injection. Ophthal Plast Reconstr Surg 2008;24(1):5557. 11. Hosal BM ZG. Ocular complication of intralesional corticosteroid injection of a chalazion. Eur J Ophthalmol 2003; 13(9 10):798 799. 12. Thomas ELLR. Retinal and choroidal vascular occlusion following intralesional corticosteroid injection of a chalazion. Ophthalmology 1986;93(3):405 407. 13. Cohen BZ, Tripathi RC. Eyelid depigmentation after intralesional injection of a uorinated corticosteroid for chalazion. Am J Ophthalmol 1979;88(2):269 270. 14. Dhaliwal U, Arora VK, Singh N, Bhatia A. Cytopathology of chalazia. Diagn Cytopathol 2004;31(2):118 122. 15. Shorr N, Seiff SR. Central retinal artery occlusion associated with periocular corticosteroid injection for juvenile hemangioma. Ophthalmic Surg 1986;17(4):229 231. 16. Moshfeghi DM, Lowder CY, Roth DB, Kaiser PK. Retinal and choroidal vascular occlusion after posterior sub-tenon triamcinolone injection. Am J Ophthalmol 2002;134(1): 132134. 17. Wilkinson WS, Morgan CM, Baruh E, Gitter KA. Retinal and choroidal vascular occlusion secondary to corticosteroid embolisation. Br J Ophthalmol 1989;73(1):3234. 18. Stapczynski JS. Localized depigmentation after steroid injection of a ganglion cyst on the hand. Ann Emerg Med 1991;20(7):807 809.

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Biosketch
Guy J. Ben Simon is a senior consultant at the Ophthalmology Department, Goldschleger Eye Institute, Tel Hashomer, Israel, and a senior lecturer at the Sackler Faculty of Medicine, Tel Aviv University, Israel. He works primarily at the Orbital, Ophthalmic Plastic and Lacrimal Surgery division. Dr. Ben Simons elds of research include orbital tumors, inammatory diseases of the orbit, thyroid eye disease, and innovations in ophthalmic plastic surgery. He has joined several voluntary missions to Africa, India, Micronesia to perform cataract surgeries and oculoplastic procedures.

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