Intralesional triamcinolone acetonide injection for the treatment of primary chalazions Michelle Y. Y. Wong, Gordon S. K. Yau, Jacky W. Y. Lee & Can Y. F. Yuen
International Ophthalmology The International Journal of Clinical Ophthalmology and Visual Sciences ISSN 0165-5701 Int Ophthalmol DOI 10.1007/s10792-014-9904-1
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Author's personal copy Int Ophthalmol DOI 10.1007/s10792-014-9904-1
ORIGINAL PAPER
Intralesional triamcinolone acetonide injection for the treatment of primary chalazions Michelle Y. Y. Wong • Gordon S. K. Yau Jacky W. Y. Lee • Can Y. F. Yuen
•
Received: 6 November 2013 / Accepted: 7 January 2014 Ó Springer Science+Business Media Dordrecht 2014
Abstract The aim of this study was to investigate the safety and efficacy of intralesional triamcinolone acetonide (TA) injection in the treatment of primary chalazions not responding to conservative treatment. Patient medical records were retrospectively reviewed for all consecutive patients that received intralesional TA injection by a single surgeon between January 2012 and March 2013 for the treatment of unresolved primary chalazions despite 1 month of conservative treatment. The dose of TA injection ranged from 2 to 6 mg (40 mg/ mL) depending on the size of the chalazion. The main outcome measures included time to resolution, time to 50 % size reduction, and complications from the treatment. During the study period, 48 chalazions from 38 patients were treated by intralesional TA injection. A 50 % reduction in size was achieved in 81.3 % of chalazions in 4 weeks and 83 % achieved complete resolution in 6 weeks. The mean time to complete resolution was 15.7 ± 10.0 days. There were no complications noted from the injections; 14.6 % required subsequent incision and curettage and 2.1 % required a second TA injection for complete resolution. Intralesional TA injection is a safe, simple, and effective procedure for the management of primary chalazions
M. Y. Y. Wong G. S. K. Yau (&) J. W. Y. Lee C. Y. F. Yuen Department of Ophthalmology, Caritas Medical Centre, 111 Wing Hong St., Kowloon, Hong Kong Special Administrative Region, China e-mail:
[email protected]
and may be considered as an alternative to incision and curettage in cases not responding to conservative treatment. Keywords Chalazion Intralesional Steroid Triamcinolone acetonide
Introduction A chalazion, also known as a meibomian gland lipogranuloma, is caused by inflammation of a blocked meibomian gland and retained meibomian secretions. It is benign and often self-limiting, and more commonly affects the upper eyelid. Patients usually present with lid swelling, pain, and symptoms of local irritation. However, larger lesions may be unsightly and may lead to complications such as corneal astigmatism, mechanical ptosis, and secondary infections [1, 2]. Treatment options for chalazions include conservative treatment with eyelid hygiene, warm compression, antibiotic eye ointment, and mild topical mild steroids [3–5]. Occasionally, systemic antibiotics are given for associated cellulitis. Surgical intervention is considered when conservative management fails. Surgical options include incision and curettage (I&C), total excision, injection of triamcinolone acetonide (TA), or carbon dioxide laser treatment [6, 7]. I&C is a painful procedure despite local anaesthesia and is especially high risk when performed in children who are not cooperative. The
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Author's personal copy Int Ophthalmol Table 1 Exclusion criteria Exclusion criteria for study patients Concurrent eyelid infection Duration of \1 month Absence of a palpable lid chalazion Recurrent chalazion Atypical features that may indicate suspicion of malignancy History of steroid-induced raised IOP Defaulted follow-up
purpose of this study was to investigate the safety and efficacy of intralesional TA injection in the treatment of primary chalazions not responding to conservative treatment.
Patient and methods This was a single centre retrospective case series from a district hospital (Caritas Medical Centre) in Hong Kong Special Administrative Region, China. Patient medical records were reviewed for all subjects who underwent intralesional TA injection for a chalazion by a single surgeon (SKY) between January 2012 and March 2013. The inclusion criteria included consecutive subjects with the diagnosis of chalazion who consented for intralesional TA injection after failed conservative treatment with lid hygiene, warm compression, and antibiotic ointment (Chloramphenicol 1 %; Shanghai Sunway Pharmaceutical Technology Co., Ltd., Shanghai, China) three times per day for at least 1 month. Exclusion criteria are shown in Table 1. Informed consent was obtained before the procedure. Ethics approval by the Hospital Authority of Hong Kong was obtained for this study. Fig. 1 Left patient with left upper eyelid chalazion. Right complete resolution 8 days after 4 mg (0.15 mL) TA injection
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Data regarding duration of symptoms as well as the size (length 9 width in millimetres) and location of the chalazion(s) were documented by digital coloured photographs of the chalazion(s) taken at every visit (Figs. 1, 2). Visual acuity, intraocular pressure (IOP) by Goldmann applanation tonometry, and a complete ophthalmological examination were performed before the injection was given. Technique for triamcinolone injection All subjects underwent the same technique for TA injection. Children \8 years were sedated with oral chloral hydrate (50 mg/kg) 30 min before the procedure [8]. Topical anaesthesia (proparacaine 0.5 %) eye drops were instilled in the affected eye before the injection. TA ranging from 0.05 to 0.15 mL (40 mg/ mL) (Stacort-A; Standard Chem & Pharm Co., Ltd, Tainan City, Taiwan) according to the size of the lesion was injected intralesionally in the out-patient treatment room (Table 3). The eyelid was inverted and the TA was injected transconjunctivally into the centre of the lesion with a 27-gauge needle. When it was not possible to evert the eyelid due to extensive swelling, the injection was given transcutaneously into the chalazion after disinfection of the skin with 70 % isopropyl alcohol wipes. No patching was required after the procedure. The patients were given chloramphenicol 1 % eye ointment three times per day to apply over the lesion and advised to continue warm compression 4–6 times per day for 10 min with a hardboiled egg. The patients were reviewed every 2 weeks after the TA injection until resolution of the chalazion. The chalazion was measured clinically (length 9 width) in millimetres. Failure was defined as an absence of maximal chalazion diameter reduction at 2 weeks
Author's personal copy Int Ophthalmol Fig. 2 Left patient with right lower eyelid chalazion. Right complete resolution 12 days after 4 mg (0.15 mL) TA injection
Table 2 Patient demographics Characteristics
Value
Number of patients
38
Number of chalazions
48
Gender Male Female
20 (53 %) 18 (47 %)
Age
2–76
Location RUL
9
RLL
19
LUL
15
LLL
5
Size (maximal diameter) \1 cm
22
1–1.5 cm
15
[1.5 cm
1
RUL right upper lid, RLL right lower lid, LUL left upper lid, LLL left lower lid
after the TA injection. Failure cases were offered I&C or a second intralesional TA injection. Main outcome measures included the size of the chalazion during each follow-up interval, time taken for a 50 % reduction in the size of the chalazion, time taken for complete resolution, and complications from the procedure. All means were expressed as mean ± standard deviation.
Results During the study period, 48 primary chalazions in 38 patients were treated with intralesional TA injections. All patients were of Chinese ethnicity with a mean age
of 26.2 ± 19.4 years (range 2–76 years). Patient demographics are summarised in Table 2. The mean duration of the chalazion before the intralesional TA injection was 2.3 ± 2.5 months. There were 45.8 % (22/48) of chalazions \1 cm in diameter, 52.1 % (25/48) of chalazions between 1 and 1.5 cm in diameter, and 2.1 % (1/48) of chalazions [1.5 cm in diameter. They were given an intralesional TA injection of 2, 4, and 6 mg, respectively, without any complications or raised IOP noted after the procedure. Seventy-seven percent (37/48) of chalazions achieved complete resolution within 4 weeks postinjection and 83.3 % (40/48) of chalazions achieved complete resolution within 6 weeks. Seventy-seven percent (37/48) of chalazions achieved a 50 % size reduction at 2 weeks and 81.3 % (39/48) of chalazions achieved the same result by 4 weeks. In total, 14.6 % (7/48) of chalazions failed to reduce in size by 2 weeks and underwent secondary I&C and 2.1 % (1/48) of chalazions received a second TA injection and achieved complete resolution 2 weeks after the second injection. The majority of failed cases had chalazions with a diameter between 1 and 1.5 cm (Table 3). One case requiring I&C had a chalazion size \1 cm. The mean time to complete resolution was 15.7 ± 10.0 days.
Discussion Chalazions are a commonly encountered eye problem due to blockage of the meibomian glands. Previous studies have shown that 29–80 % of chalazions resolved with conservative treatment alone [9–12]. The results of our study suggest that intralesional TA injection was an effective and safe treatment modality
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Author's personal copy Int Ophthalmol Table 3 Dosage of intralesional TA injection and outcome of treatment according to size of lesion \1 cm (n = 22)
1–1.5 cm (n = 25)
[1.5 cm (n = 1)
Dosage of intralesional TA injection (mg/mL)
2/0.05
4/0.1
6/0.15
Distribution by size of chalazion (%)
45.8
52.1
2.1
Percentage of chalazions that resolved after a single TA injection (%)
95.5
72.0
100 (only 1 case)
Percentage of chalazions that require secondary I&C (%)
4.5
24.0
0
Percentage of chalazions that required a second TA injection (%)
0
4.0
0
Time taken to complete resolution (days)
16.1 ± 10.8
18.3 ± 10.1
14.0
for primary chalazions not responding to conservative treatment. Complete resolution of the chalazion was achieved in 83.3 % of treated lesions at a mean of 15.7 ± 10.0 days. A single injection was sufficient in most cases and only one case required a second injection. Our regimen of titrating the volume of TA injection according to the size of the lesion appears to be effective for chalazions \1.5 cm. For chalazions \1 cm, 2 mg of TA was effective and resulted in complete resolution in 95.5 % of chalazions. For larger lesions between 1 and 1.5 cm, 72 % of chalazions achieved complete resolution with a single TA injection of 4 mg. It seems that chalazion size at presentation was an important determinant of success for TA injection, with larger lesions more likely to need subsequent I&C or a second TA injection. Our findings are consistent with those of Palva and Pohjanpelto who reported that larger lesions were associated with a lower rate of resolution by intralesional corticosteroid injection and a high rate of recurrence [12]. However, in our series, one chalazion [1.5 cm had complete resolution after a single TA injection although there were no other chalazions of this diameter to allow us to draw solid conclusions about the success of TA in such large lesions. An intralesional steroid injection offers the advantage of a quick, simple, and less painful procedure compared to I&C. In the younger age group, apart from the psychological aversion to surgery, it may be difficult to perform I&C as they may not be able to cooperate, and sometimes general anaesthesia is necessary. Comparatively, I&C is a longer procedure that requires injection of local anaesthesia and may be associated with more complications such as pain, bleeding, and scarring. In addition, patching of the eye is often necessary after the procedure. On the other
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hand, an intralesional TA injection is a procedure that requires minimal facilities and time, and can be performed in eyes with multiple chalazions as well as on lesions that are close to the lacrimal punctum with minimal risk of damaging the adjacent eyelid structures. Our success rate (83 %) was similar to earlier studies that reported success rates of 62–92 % after intralesional steroid injections for chalazions [11–22]. One of the earliest studies by Watson and Austin in 1984 found that 77 % of chalazions resolved with a 0.22-mg injection of steroid suspension compared to 90 % in the I&C group [14]. Since then, various publications have affirmed a similar success rates between intralesional steroid injection (80–84 %) and I&C (87–89 %), with a slightly higher success rate in the latter [11–15]. More recently, however, Simon et al. [16, 17] reported a higher success rate with a 4-mg intralesional TA injection (81 %) compared to I&C (79 %). Regarding time taken for resolution, Pavicic´-Astalos et al. [18] found that 95 % of chalazions decreased in size by 80 % with no recurrence after an intralesional TA injection of 4–8 mg, with a mean time to resolution of 15.27 days, which is comparable to our findings (15.7 ± 10.0 days). Regarding the route of administration, TA injections can also be performed subcutaneously, outside the lesion. Ho and Lai described the use of a 2-mg subcutaneous TA injection in which 54.2 % of treated chalazions resolved completely with one injection, and 35.4 % resolved after two injections [23]. In their series, two patients developed skin depigmentation at the site of the injection. Similarly, Chung et al. [24] found that 93.8 % of treated chalazions achieved complete resolution with a 3-mg subcutaneous TA injection.
Author's personal copy Int Ophthalmol
We did not encounter any complication from the intralesional TA injections. Reported complications include yellow deposits at the site of injection [19], raised IOP, and skin hypopigmentations [23–25]. More serious adverse events include inadvertent globe penetration, traumatic cataract [26], microembolisation, and infarction of retinal and choroidal vasculature [27]. Our study had limitations. It was retrospective in nature and represented only a single centre. The treatment modality was not randomised and there was no control group. Furthermore, the population consisted mainly of small and medium-size lesions with only one case with a chalazion[1.5 cm. Nevertheless, we have demonstrated that a single intralesional injection of TA through a transconjunctival approach, with dose titration according to lesion size, was able to achieve complete resolution in 83 % of treated chalazions in 16 days. TA injections may be a simple, safe, and effective treatment alternative for primary chalazions that do not respond to conservative treatment.
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