Conservative

Treatment of Chalazia
HENRY D. PERRY, MD,*t RONALD A. SERNIUK, MD*

Abstract: Recently, several authors have vived interest in intralesional corticosteroid

C') revived interest in intralesional cortico- therapy of chalazia.' Many ophthal-
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w steriod therapy of chalazia. Most ophthal- mologists use surgical excision to treat
these lesions. We feel before either method
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2 mologists use surgical excision to treat
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z these lesions. We feel that before either is advocated as definitive, a more conser-
method is advocated as definitive, a more vative therapeutic approach should be
....
co conservative therapeutic approach should evaluated. In an attempt to determine the
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be evaluated. In an attempt to determine effectiveness of conservative therapy we
::J the effectiveness of conservative therapy, studied consecutive patients with chalazia
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0 we studied consecutive patients with treated only by lid hygiene.
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• chalazia treated only by lid hygiene. The
study consisted of 37 patients, 19 men and
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18 women, ages 14 to 62 with a total of 4 7 PATIENT POPULATION AND
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chalazia. Thirty-six chalazia resolved with METHODS
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conservative therapy; 4 chalazia remained
2 the same, and in two patients, small Thirty-seven con~ecutive patients with
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pyogenic granulomas developed. These one or more presumed chalazia of one or
(.') figures indicate that conservative therapy more eyelids provided the basis for this
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-' was approximately 80% effective in treat- study. All patients were examined by one
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2 ing chalazia. [Key words: chalazia, or both of the authors. The study began in
-'
<( pyogenic granuloma.] Ophthalmology 87: June 1978 and concluded in March 1979.
I
218-221, 1980
I-
I The clinical diagnosis was based on history
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0 and the appearance and location of the le-
Chalazia are chronic inflammations of the sions.
meibomian glands which represent one of Patients were screened for comprehen-
the more common problems seen by sive parameters. Pretreatment data in-
ophthalmologists. Although these lesions cluded age, sex, race, ocular history in-
are cosmetically disfiguring, they are not cluding duration and previous history of
dangerous and, therefore, treatment has chalazia, ocular tension, location and size
been mainly through empirical means. Re- of the lesion to the r..earest millimeter, slit-
cently, several ophthalmologists have re- lamp examination, and a detailed fundus
examination (Table 1). Schirmer strip test-
ing and corneal sensitivity were performed
From the Walson Army rjospital,* Fort Dix, NJ and the on the first 18 patients. External photo-
Long Island Jewish~Hillside Medical Center,t New
Hyde Park, NY. graphs were taken of each patient at the
initial and follow-up visits using the
Presented at the Eighty-Fourth Annual Meeting of the
American Academy of Ophthalmology, San Fran-
Donaldson stereo anterior segment camera.
cisco, November 5~9, 1979. Patients, after the initial examinations,
were examined at two, four, six, and twelve
Reprint requests to Henry D. Perry, MD, Department of
Ophthalmology, Long Island Jewish~Hillside Medi- weeks, and more often if needed.
cal Center, New Hyde Park, NY 11040. Treatment was initiated in all patients by
The above assertions are the private views of the au-
use of a physician- patient conference.
thors and in no way reflect the views of the Depart- Each patient was told that his disease was
218 ment of the Army or the Department of Defense. due to a blockage of one or more of the
Table 1. Patient Profile
Sex: 19 Men, 18 Women
Age: 14 Months to 62 Years (median: 32 years)
Race: 20 Blacks, 17 Whites
History: Positive in 15 Patients
Duration: 1 Day to 1 Year (median: 10 weeks)
Right Eye: 23 chalazia; Left Eye: 24 chalazia
Lesion Size: 2 to 12 mm (median: 5 mm)
excretory ducts of the meibomian glands.
They were further advised that the resolu-
tion of the problem depended upon their
alleviating the blockage of the meibomian
glands by means of lid hygiene (Table 2).
This blockage of the ducts leads to in-
creased intraductal pressure resulting in
necrosis of the walls of the gland and liber-
ation of contents inside the lid. Normally,
the glandular contents empty into the tear
film. Therefore, when the liberation occurs
inside the eyelid, the body recognizes this
lesions since surgical treatment could dam-
age normal adjacent ducts.
If after six weeks there was no improve-
ment of the lesions on conservative treat-
ment, intralesional corticosteroid injection
was performed according to the method of
Pizzarello et al and repeated one time if
necessary. The remaining lesions that still
failed to respond to therapy were then sur-
gically excised.
RESULTS
As shown in Table I, there were I9 men
and I8 women. Patients ranged in age from
I4 months to 62 years, with the median age
of 32. Twenty patients were black and I7
white. Fifteen patients had a positive his-
tory of previous chalazia. The duration
varied from one day to one year with a me- <(
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dian of IO weeks. The right eyelid was in- <(
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material as being foreign and there is an in- volved in 23 cases of chalazia, 13 upper lid <(
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flammatory reaction against this material. and IO lower lid. The left eye was involved 0
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This is the reason why initially the lesion is in 24 cases of chalazia, with equal distribu- 0
red and painful. However, as time pro- tion between the upper and lower lids. A f-
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gresses, the inflammatory reaction becomes total of 37 patients had 47 chalazia. Eight ::?:
less and less. The patients can help alleviate patients had two chalazia, and one patient f-
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this problem by applying warm saline soaks had three. The lesion size varied from 2 mm a:
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to the eyelids a few times a day and by to I2 mm with a median of 5 mm. w
Thirty-five chalazia resolved (29 patients) >
using a moistened cotton-tipped applicator f-
to the base of the eyelashes. In this fashion, for a success rate of 76.6% (Table 3). Res- <(
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olution occurred in 2.8 weeks (range 2 days a:
the blocked duct openings may be cleared w
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and drainage of their contents re- to 4 weeks). Resolution was judged by dis- z
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established. The patients were reassured appearance of the mass or decrease in size 0
that this was a benign lesion and that if they to I mm in diameter or less. Five patients •
followed the instructions carefully, it was remained the same (9 chalazia), one patient ~
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very likely the lesion would completely re- was lost to follow-up, and two patients de- z
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gress within a period of two to four weeks. veloped pyogenic granuloma, thus, I2 fail- w
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They were also advised that conservative ures on conservative therapy. Nine failures 0
therapy was the best way of curing these were treated by injection, five responded z
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Table 2. Instructions for Lid Hygiene ()_

Lid Hygiene
This is a simple way to alleviate the problems of seborrheic blepharitis, chronic conjunctivitis and chalazion.
It represents an attack on the accumulated oil secretions of the lid glands. The normal secretions are released
through small pores in front of the lashes of the eyelid. In some people these secretions accumulate and lead to
many different problems. The key to treating all these problems is to clear the lid margins of these built-up se-
cretions. Lid hygiene is the means to achieve this end.
Warm Saline Soaks
One-half teaspoon of table salt with one quart of warm water will give a saline solution (salt water) that is
equal to that in the normal body fluids. This salt water should be warm to hot, but be careful not to make
it too hot since the skin of the eyelids is the thinnest in the body and is very easily burned. Use sterile
cotton balls soaked in the salt water solution that have been slightly wrung. Place one on the eye with
the lids closed and let it remain until it cools. Replace with fresh warm cotton balls and continue this for
ten minutes. This will dissolve the secretions, help soothe burning eyes, and decrease the redness of the
lids.
Cleaning the Lashes
Using a cotton-tipped applicator moistened with warm to hot salt water, the lashes are gently brushed
from the base toward the ends of the lashes. In the upper lid this is easy since the eye can remain closed.
In the lower lid it is more difficult and requires extra care. Pull down the lower lid so as to avoid
brushing the cotton-tipped applicator against the cornea. The lashes should be cleansed twice a day for the
first week.
2I9
 Table 4. Overall Results
Table 3. Treatment Results
29 Patients, 35 Chalazia resolved 76.6%
29 Patients: 35 Chalazia resolved
30 Patients, 36 Chalazia 78.3%
6 Patients: 10 Chalazia remained the same
30 of 36 Patients 83.3%
2 Patients: Developed pyogenic granulomas
Twelve Treatment Failures
1 lost to follow-up
9 received intralesional steroids
5 responded after 1 injection
1 responded after 2 injections
3 were surgically excised DISCUSSION

The only series in the literature dealing

after one injection and one more after two
injections. The remaining three lesions
were surgically excised. One of these three
was found to be an epithelial inclusion cyst
and represented a misdiagnosis. Of the two
pyogenic granulomas, one resolved spon-
taneously while awaiting scheduled surgical
excision (Fig 1). The other pyogenic
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granuloma was excised. The one patient
a: lost to follow-up was counted as a treat-
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(!) ment failure. If the misdiagnosis is deleted
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z sponded to conservative therapy included
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r-- as a success, the final statistics show 30 pa-
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w tients had resolution of 36 chalazia, 78.3%.
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In terms of patients, 30 of 36 had resolution
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of their chalazia for a success rate of 83.3%
> (Table 4).
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The average follow-up was 2.9 months
co (range 6 weeks to 9 months). During the
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with treatment of chalazia reported the use
of intralesional injections of corticosteroids
in 12 patients with 17 chalazia. 1 Fifteen of
17 chalazia were cured with one or more
injections. The only complication was dis-
coloration of the skin at the site of injection
in a black patient. The overall success rate
was 88.2%. It was not clear if these two
failures occurred in one or two patients.
Therefore, their success rate in terms of
patients was either 92.0% or 83.3%. These
figures are not far from the results achieved
in our larger series of patients treated by
conservative means alone.
The conservative approach to chalazia is
an effective means of treatment. We feel
the key to our success was the use of a
physician-patient conference. In this con-
ference the patient was given a logical ex-
planation for the cause of his problem and

I
follow-up period, three patients developed presented with a nontraumatic means of
0
a: four additional chalazia. Three chalazia re- curing his disease. The patients are usually
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sponded to conservative therapy and one to cooperative and motivated to effect treat-
ment themselves. Thus, there occurs a
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intralesional injection. The secondary
chalazia of these three patients were not in- basic shift in responsibility from the physi-
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0 cluded in the tabulation of data. cian to the patient.
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0 The results of the Schirmer tests and In our study we expected patients who
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__j corneal sensitivity were within normal had had chalazia of long duration to be re-
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I limits. sistant to therapy. Yet, of the 12 patients
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I with chalazia of six months duration or
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0 longer, eight had resolution of their lesions.
The presence of a positive history or the
size of the chalazion also did not prove to
be of value in predicting unresponsiveness
to conservative therapy. The only predic-
tive situation we observed was the presence
of two chalazia in a patient with a positive
history. Of the five patients in this group,
three failed to respond to conservative
therapy.
The motive for our study was the concern
that indiscriminate use of intralesional in-
jections may lead to serious complications.
It is well documented that cases of acci-
dental perforation of the globe have oc-
curred by ophthalmologists performing
periocular injections. 2 However, many
physicians who treat chalazia are not
ophthalmologists and the unrestricted use
Fig 1. External photograph of the left eye lower eyelid of intralesional injections in or around the
showing a pyogenic granuloma. Spontaneous resolu- eyelids on a large scale will surely result in
220 tion occurred within two weeks. serious ocular complications. 3 At present
we are treating all our patients conserva-
tively and reserve the more invasive proce-
dures for treatment failures.
REFERENCES
therapy of chalazia. Am J Ophthalmol 1978;
85:818.
2. Schlaegel TF Jr, Wilsom FM. Accidental in-
traocular injections of depot corticosteroids.
Trans Am Acad Ophthalmol Otolaryngol 1974;
78 847.

3. Perry HD, Nauheim JS, Cameron CD. lntravitreal

1. Pizzarello LD, Jakobiec FA, Hofeldt AJ, Podolsky injections by a dermojet syringe. Ann Ophthalmol
MM, Silvers ON. lntralesional corticosteroid 1977; 9:737.

Discussion
by
Dan B. Jones, MD
The results of this study suggest that the bing the lid margins with a moistened cotton-
majority of chalazia should resolve within six tipped applicator contributes to resolution of
weeks following some form of conservative, chalazia.
noninvasive therapy. In the authors' restricted In a recent study of chalazia, Bohigian 1 de- <(
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patient population, 30 of 36 patients (83%) re- tected no difference in cure rate among patients <(
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sponded to heat and lid hygiene. In the absence applying hot moist packs four times daily as <(
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of an untreated control group or other popula- compared with a group applying hot moist packs 0
tion, the significance of the population group, and instilling sulfisoxasole 10% drops four times lL
0
patient conference, and treatment plan cannot daily. Overall, 24 of 47 chalazia (57%) resolved 1-
be determined. Although the patient source is within four weeks. The basis for the difference in z
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not defined, it is assumed that the majority, if the success rate in these two studies is not ap- ::;;:
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not all, were derived from military personnel and parent but may relate to the longer period used <(
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dependents seeking medical care at the Walson to define treatment failure (six weeks) and to a:
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Army Hospital at Fort Dix, New Jersey. It is other factors in this current series. w
conceivable the study may have selected Based on the results of this study, the authors' >
f=
chalazia less severe than would otherwise be en- recommendations for management of chalazia <(

countered by a non-military ophthalmologist in a seem appropriate. Regardless of patient age or >

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general practice by factors such as ease of size, location, or even duration of the lesion, (f)

availability and lack of expense of medical care chalazia should be initially treated with some z
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and recruitment of patients with asymptomatic form of conservative therapy, perhaps heat and 0
chalazia. In the physician-patient conference, encouragement. Oral or topical antibiotics are •
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patients were advised that the resolution of the not indicated. Lesions failing to resolve within :::)

lesion essentially depended on their alleviating
the blockage of the meibomian glands by lid
hygiene and that, if required, surgical treatment
may damage normal tissue adjacent to the le-
sions. If heat and lid hygiene are effective, this
conference should have enhanced patient com-
pliance and favorably contributed to the results
in this series. Although the majority of ophthal-
mologists would probably agree that heat con-
tributes to the resolution of chalazia, I am un-
aware of a controlled study that has established
the efficacy of heat or lid massage. The exact
pathogenesis of chalazia has not been defined.
Considering, however, that the lesion is a sterile
lipogranuloma, heat may promote absorption of
material, or drainage through skin, conjunctiva,
or meibomian orifice. Evidence suggests that
the pathogenesis and structural alterations
of chalazia are similar to the skin lesions in
acne vulgaris. Application of heat alone, how-
ever, has very little benefit in the treatment
of established acne lesions. It is difficult
to imagine the mechanism by which scrub-
From the Department of Ophthalmology, Baylor Col-
lege of Medicine, Cullen Eye Institute, Houston.
four to six weeks may respond to intralesional z
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corticosteroid. Pizzarello and associates 2 re- w
(f)
ported resolution of 13 of 17 chalazia (12 pa- 0
tients) following one or two injections of 0.05 ml z
<(
(0.25 mg) to 0.2 ml ( 1.0 mg) of triamcinolone >-
acetonide (I 0 mg/ml diluted to 5 mg/ml with a:
a:
saline). In the current studies, six of nine w
0...
chalazia resolved following injection, although
the time was not stated. Until additional data are
available, the indications, safety, and efficacy
for intralesional corticosteroids cannot be de-
fined. Despite the site of injection and relatively
small amount of drug utilized, potential compli-
cations include skin discoloration; atrophy of the
epidermis, dermis, and fat; visible retention of
drug and vehicle; prolonged drug effect on the
eye; and accidental intraocular injection.
REFERENCES
1. Bohigian GM. Chalazion: a clinical evaluation.
Ann Ophthalmol 1979; 1397.
2. Pizzarello LD, Jakobiec FA, Hofeldt AJ, et al. ln-
tralesional corticosteroid therapy of chalazia. Am
J Ophthalmol 1978; 85:818

221