Download Original Article - Eyelid surgery by London UK eyelid specialist Miss

Clinical and Experimental Ophthalmology 2007; 35: 706–712
doi: 10.1111/j.1442-9071.2007.01617.x
Original Article
A prospective randomized treatment study comparing three
treatment options for chalazia: triamcinolone acetonide
injections, incision and curettage and treatment with
hot compresses
Amynah Goawalla MRCOphth and Vickie Lee FRCOphth
Central Eye Unit, ACAD Centre, Central Middlesex Hospital, London, UK
ABSTRACT
Background: Three methods of treating chalazia were
compared: intralesional triamcinolone acetonide injections
(0.2 mL of 10 mg/mL), incision and curettage and advice
regarding the application of hot compresses to the affected
eyelid.
Methods: This was a single centre randomized treatment
study. Patients with a chalazion underwent either of the
three treatment options. Chalazion resolution, pain, satisfaction and inconvenience experienced because of treatments
were the outcomes assessed via a telephone interview at
3 weeks.
Results: 136 consecutive patients were enrolled into the
study. At the 3-week follow up, the resolution rates in the
triamcinolone acetonide injection and surgical treatment
groups were not significantly different from each other at
84% (47/56) and 87% (39/45), respectively (P < 0.001), but
was significantly lower in the conservative treatment group
at 46% (16/35) (P < 0.001). Pain scores were higher in the
surgical treatment group compared with the triamcinolone
injection group (P < 0.003). Inconvenience experienced by
patients was reported as significantly less in the triamcinolone group compared with the conservative and surgical
treatment groups (P < 0.001). Patient satisfaction scores
were lower in the conservative treatment group compared
with each of the other two groups which in turn, were
no different from each other regarding this outcome
(P < 0.001).
Conclusions: To our knowledge, this is the first prospective
randomized study comparing the three methods of chalazia
treatment. Results suggest that a single triamcinolone
acetonide injection followed by lid massage is almost as
effective as incision and curettage in the treatment of chalazia and with similar patient satisfaction and less pain and
patient inconvenience.
Key words: eyelid,
triamcinolone.
meibomian
gland
dysfunction,
INTRODUCTION
Chalazia are localized cysts of lipogranulomatous
inflammation. Cosmetically, they can be unsightly; occasionally, if large enough they can obscure vision1 and rarely, they
can lead to conjunctivitis or cellulitis.2 Patients are usually
initially advised to apply hot compresses (H/C) to the cyst
with a wet flannel to encourage it to spontaneously drain.
Previous studies have found a 25–50% resolution rate with
this conservative treatment.3,4 Failing this, they are treated
surgically by incision and curettage (I&C) under a local
anaesthetic injection. In the late 1970s, treatment with localized steroid injections was first described.5 Since then, there
have been a few prospective interventional studies investigating the efficacy, simplicity and safety of intralesional triamcinolone acetonide (TA) in the treatment of chalazia6–8
(Table 1). Local skin depigmentation has been reported following transcutaneous injections but this adverse effect
is minimized through transconjunctival injection.9–11 Ben
Simon et al.8 suggested that patients preferred steroid injections to surgery. In addition, accidental globe penetration
䊏 Correspondence: Miss Vickie Lee, Ophthalmology Department, ACAD Centre, Central Middlesex Hospital, London NW10 7NS, UK. Email:
[email protected]
Received 4 March 2007; accepted 31 July 2007.
© 2007 The Authors
Journal compilation © 2007 Royal Australian and New Zealand College of Ophthalmologists
Triamcinolone acetonide for chalazia
707
Table 1. A summary of previous studies investigating the efficacy of TA in the treatment of chalazia
Chalazia resolution with
triamcinolone injection
Watson et al. (1984)6
Ho & Lai (2002)7
Ben Simon et al. (2005)8
Ahmad S et al. (2006)9
77% (n = 39)
with 1–2 injections
89.6% (n = 43)
54.2% with one injection
25.4% with two injections
80% (n = 155)
60% with one injection
20% with two injections
80% (n = 66)
62% after one injection
12% after two injections
has been reported as a result of a transcutaneous injection of
TA into a chalazion.12
To date, there have been no randomized treatment
studies, comparing these three standard chalazia treatments
which forms the main objective of our study. The secondary
objective was to compare patients’ preferences of the
treatment options, documenting pain experienced during
and after each treatment, the amount of inconvenience the
patients perceived the treatments caused and their overall
level of satisfaction with the different treatments.
METHODS
This was a single centre randomized prospective interventional study. A single investigator (AG) administered all the
TA injections and I&C. Ethics committee approval was
obtained prior to commencement of the study. One hundred
and thirty-six adult patients were recruited into the study
over a period of 8 months from August 2005 to March 2006.
The final cohort consisted of 83 women and 53 men. The
inclusion and exclusion criteria for recruitment are set out in
Table 2. Patients were consecutively assigned one of three
methods to treat their chalazia in a block randomization
fashion13 whereby blocks of five or 10 patients would consecutively undergo one of the three treatment options. These
were I&C under a local anaesthetic, a 0.2-mL transconjuctival
injection of 10 mg/mL of TA into the cyst followed by advice
to massage the lid, or advice regarding H/C to the cyst with
a warm, wet flannel.
Technique of TA Injection
The conjunctiva was anaesthetized with a drop of 0.5%
proxymethocaine. The eyelid was everted and a 28 gauge
needle on a 1-mL insulin syringe was used to inject 0.2 mL of
10 mg/mL TA (Adcortyl, E.R. Squibb & Sons Ltd, Uxbridge,
Middlesex, UK) transconjunctivally into the chalazion as
illustrated in Fig. 1. The eye was not padded after the procedure but the patient was given chloramphenicol ointment to
apply to the treated eye three times daily for 5 days and was
instructed to apply gentle digital massage over the chalazion
Chalazia resolution with
incision and curettage
90% (n = 30)
with 1–2 operations
89% (n = 75)
79% after one operation
10% after two operations
Table 2. Inclusion and exclusion criteria for study patients
Inclusion criteria:
Male and female patients over 18 years of age of all ethnic groups
Patient with a palpable chalazion on any eyelid
Patients with multiple chalazia but only single one on each lid
Normal lid anatomy enabling lid eversion and transconjunctival
injection
Exclusion criteria:
Patients with chalazia which have atypical features (a recurring
chalazion, abnormal surrounding lid tissue, associated loss of
lashes)
that may indicate suspicion of malignancy
Patients allergic to any of the agents being used in the
study (proxymethocaine, chloramphenicol, lignocaine, triamcinolone acetonide)
Patients under 18 years of age
Patients without a palpable lid chalazion
Patients with multiple chalazia on one eyelid
Patients unable to give consent (even with the assistance of a
translator if necessary)
Patients with a concurrent eyelid infection (cellulitis or
conjunctivitis)
for 5 min after each ointment application. Occasionally, some
resistance was felt on penetrating the cyst wall with the
injection but in all cases, the TA was injected intralesionally.
Incision and curettage
A 1-mL subcutaneous injection of 2% lignocaine with a
25 gauge needle was used to anaesthetize the eyelid and
the conjunctiva was anaesthetized with a drop of 0.5%
proxymethocaine. The eyelid was everted and a lid clamp
placed. A vertical incision through the tarsal plate into the
meibomian gland was made and a curette inserted into
the chalazion to brake up the loculations and drain the
chalazion. Chloramphenicol ointment was then applied to
the treated eye and it was double padded. The patient was
advised to keep the eye padded for at least 2 h and was given
chloramphenicol ointment to apply to the affected eye three
times a day for 5 days.
© 2007 The Authors
Journal compilation © 2007 Royal Australian and New Zealand College of Ophthalmologists
708
Goawalla and Lee
Conservative treatment
The patient was shown how to apply heat a H/C (a clean
flannel dipped in hot water) to the affected lid and gently
massaging the lid to encourage the chalazion to spontaneously drain. They were instructed to spend 5–10 min applying H/C to the chalazion three times daily for 5 days
followed by chloramphenicol ointment which was given to
the patient to take away.
Assessment of outcomes
followed up. The primary outcome measured was whether or
not the chalazion had completely resolved. Complete resolution was defined as no longer having a palpable lesion at
the location of the original chalazion. Patients were asked to
check and report over the telephone whether or not they
could feel a lump when palpating over the lid. Although less
reliable than physically following up patients, this method of
follow up was used because of the high attendance failure
rate at Central Eye Unit. Secondary outcomes measured
were as follows:
1
Patients were followed up via a telephone questionnaire
(Table 3) 3 weeks after their treatment. The time frame and
mode of follow up was decided upon based on the findings
and design of Simon et al.’s study in which the average time to
resolution of chalazia after one TA injection was 2.5 weeks.
In this study patients’ visual acuities and intraocular pressures
(IOP) were also followed up, and no significant change in
IOP of visual acuities was found in patients as they were
Figure 1. Transconjunctival injection of Triamcinolone into the
lower eyelid.
2
3
The perceived level of pain experienced during and
after the treatment.
The perceived level of inconvenience the treatment and
aftercare caused the patient.
The overall level of satisfaction with the treatment
(taking into account the success of the treatment, the
pain the treatment caused, the time and inconvenience
the treatment took in terms of the burden of aftercare
and interruption to daily activities such as driving).
Telephone questionnaires were used because of high
failure rates of patients attending follow-up appointments
previously noted in our minor operations clinic. Fortunately,
no patients were lost to follow up. We used a simplified
version of the 11-point Numerical Rating Scale14 whereby
patients were asked to rate the level of pain they experienced
during the treatment they underwent for their chalazia and
over the hours and days following the treatment. Patients
were asked to score their overall experience of pain on a scale
of 0 to 10 whereby 0 meant that no pain was experienced
whatsoever and 10 equalled ‘the worst pain they had ever
experienced’. For simplicity, a scale of 0 to 5 was used to
score questions two and three of the secondary outcome
measures whereby 0 was equivalent to ‘no inconvenience
caused’ for question two, or ‘completely unsatisfied with the
treatment’ for question three. Conversely, a score of 5 signified that the treatment and aftercare incurred ‘excessive
Table 3. Follow-up telephone questionnaire
Follow-up telephone questionnaire
Please circle the answer indicated by the patient over the telephone
Questions
1. Has your eyelid chalazion completely resolved?
Yes No
2. On a scale of 0–10 how would you describe the pain you experienced during and after your treatment during the postoperative period
when you went home?
(No pain at all) 0 1 2 3 4 5 6 7 8 9 10 (Extremely painful)
3. On a scale of 0–5, how burdensome was your treatment and aftercare in terms of causing you inconvenience? (For example, were you
able to drive or return to work straight afterwards? Did you have difficulty applying the ointment and/or massage to the treated eye at
home? Did your treatment restrict you in any other way?)
(Not burdensome at all) 0 1 2 3 4 5 (Extremely burdensome)
4. On a scale of 0–5, how would you rate your overall level of satisfaction with the treatment you received? (You may want to consider
how successful the treatment was, how restrictive the treatment and aftercare was, how painful it was and whether you had significant
bruising after the treatment.)
(Completely dissatisfied) 0 1 2 3 4 5 (extremely satisfied)
Patient identification number:
© 2007 The Authors
Journal compilation © 2007 Royal Australian and New Zealand College of Ophthalmologists
Triamcinolone acetonide for chalazia
Figure 2. Treatment
Algorithm
for Study. I&C, incision and curettage; TA, triamcinolone acetonide.
709
Patients were block randomised into one of three treatment
groups: A, B and C as follows:
(A) Have surgical
treatment under
local anaesthetic
(B) Have steroid
injection into cyst to
treat it
(C) Antibiotic
ointment and hot
compresses
Follow up via telephone after 3 weeks to find out if eyelid cyst had completely resolved
If cyst had completely resolved then patient
was discharged
Patients in group A, were
offered re-treatment via
I&C
If the cyst had not completely resolved then the
patient was offered a clinic appointment 3
weeks from the telephone call for a second
treatment
Patients in group B were
offered a second TA injection
Patients in group C
were offered I&C
Follow up via telephone after 3 weeks to find out if eyelid cyst has completely resolved
If cyst had completely resolved then
patient was discharged
inconvenience to the patient’ (for question two) and ‘complete satisfaction with the treatment and aftercare’ (for question three) (Table 3).
Patients who reported that their chalazion had completely resolved after their first treatment were discharged.
All the remaining patients (including those patients whose
chalazia had partially resolved) were offered a 3-week
follow-up appointment (6 weeks after their first treatment)
for a repeat of their original treatment, apart from patients
who had been assigned to conservative treatment. These
patients were retreated by I&C at this second clinic appointment and were followed up 3 weeks later via a second telephone call (at 9 weeks). If the chalazion had still not resolved
by this point, these patients were booked into an oculoplastics clinic for assessment and further management of the
chalazion. (See Fig. 2 for a summary of this treatment
pathway.)
Multiple chalazia
Patients with more than one chalazion on the same eyelid
were excluded from the study but patients with more than
one chalazion, each on different eyelids, were included in the
study and were assigned to one of the three treatments to
If the cyst had not completely resolved then
patients were referred to the oculoplastics clinic
for further assessment and treatment from there
treat all their chalazia. The rationale behind this is first, that
treating chalazia in close proximity to one another might
introduce a confounding factor into the study, influencing
resolution outcomes. Second, patients with multiple chalazia
suitable for inclusion in the study had to receive the same
treatment for all their chalazia, otherwise it would not have
been possible for them to score the secondary outcomes
regarding inconvenience caused by their treatment and aftercare and their overall satisfaction with their treatment.
However, in order to enable an independent samples comparison, even if a patient was treated for multiple chalazia,
he or she was included as one sample in the cohort.
Such patients therefore had to be excluded from the study
if the outcomes of the treatments on different eyelids were
variable.
Statistical analysis
There were four outcome variables, the primary outcome
being whether the chalazia had resolved and three secondary
outcomes (detailed as described earlier), namely: the
patient’s pain experience, the inconvenience caused to
the patient and the patient’s overall satisfaction with the
treatment.
© 2007 The Authors
Journal compilation © 2007 Royal Australian and New Zealand College of Ophthalmologists
710
Goawalla and Lee
Table 4. Overall differences between the three treatment groups
Outcome
Chalazion resolved at 3 weeks
Group
H/C
n (%)
No
Yes
Outcome
Scale
Pain
Inconvenience
Satisfaction
0–10
0–5
0–5
TA
n (%)
I&C
n (%)
19 (54%)
16 (46%)
9 (16%)
47 (84%)
6 (13%)
39 (87%)
H/C Median
(IQR)
TA Median
(IQR)
I&C Median
(IQR)
6 (5, 7)
2 (1, 2)
4 (3.3, 5)
7 (5.5, 8)
3 (2, 4)
4 (3, 4)
0 (0, 0)
4 (3, 4)
2 (0, 4)
I&C, incision and curettage; IQR, interquartile range; TA, triamcinolone acetonide.
Whether the chalazia had resolved was measured as either
yes or no, and can be viewed as a categorical variable. The
chi-squared test was used to compare if there was an overall
difference in the outcomes between the three groups. Subsequently, the chi-squared test was also used to examine if
there was a difference between any two treatment groups.
These subsequent analyses required further statistical tests,
and because several comparisons between groups were made
there was more chance of finding a difference between treatments due to chance. Therefore, this was accounted
for by performing a Bonferroni correction to the analysis
results. This involved multiplying the P-values resulting from
each test by the number of comparisons made (three in this
case).
The other three outcomes, patient pain, inconvenience
and satisfaction, were measured on an ordinal scale. Therefore, the Kruskal–Wallis test was used to compare the overall
difference in scores between the three groups. Subsequently,
the Mann–Whitney test was used to compare between pairs
of treatments. Again a Bonferroni correction was applied to
allow for the fact that several comparisons are made.
The significance of the results was determined from the
P-values which result from each analysis. A P-value of <0.05
was usually regarded as evidence of a statistically significant
result.
RESULTS
Chalazion resolution
The results showed a significant difference in chalazion resolution between H/C group and each of the other two groups,
but no significant difference between the TA and I&C groups.
After a single treatment session, the TA and I&C groups
performed the best with 84% (47/56) and 87% (39/45) of
chalazia resolved in each group, respectively, compared with
only 46% (16/35) in the H/C group. Of the remaining 16%
(9/56) of patients whose first TA injection was unsuccessful,
a further three chalazia resolved after a second TA injection,
increasing the overall resolution rate with TA to 89% (50/56)
in this treatment group. The remaining six patients in the TA
group were then treated successfully by I&C in the oculoplastics clinic. The resolution rate increased to 100% (45/45)
Table 5. Specific comparisons between pairs of groups
Outcome
Chalazion resolved
Pain
Inconvenience
Satisfaction
H/C vs. TA
P-value
H/C vs. I&C
P-value
TA vs. I&C
P-value
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
0.86
<0.001
1.00
0.003
<0.001
0.09
Bold figures indicate statistically significant (P < 0.001). I&C,
incision and curettage; TA, triamcinolone acetonide.
in the I&C group after a second treatment and therefore none
of these patients needed to be referred to the oculoplastics
clinic. All patients in the H/C group whose chalazia
remained unresolved at their telephone follow up (19/35)
were given follow-up appointments for I&C of their chalazia.
Seventeen of these 19 patients subsequently underwent successful I&C with complete resolution of their chalazia and
the remaining two were lost to follow up after referral to the
oculoplastics clinic.
Chalazion resolution rates and the median as well as interquartile ranges of the other outcomes measured are summarized in Table 4. Specific comparisons between pairs of
groups were made using the chi-squared test for chalazion
resolution and the Mann–Whitney test for all other
outcomes. These results are summarized in Table 5. The
figures presented the Bonferroni-adjusted P-values for each
pairwise comparison.
Pain experienced during and after treatment
There was a significant difference in pain between all pairs
of treatment groups. The pain scores were highest in the
I&C group with a median score of 7, followed by a median
score of 6 in the TA group and lowest in the H/C group
with a median score of 0. There was a significant difference
in pain scores reported by the I&C group compared
with the TA group which was statistically significant
(P = 0.003).
© 2007 The Authors
Journal compilation © 2007 Royal Australian and New Zealand College of Ophthalmologists
Triamcinolone acetonide for chalazia
Patient inconvenience
The results for inconvenience indicated that there was a
significant difference between the TA group and each of the
other two groups. The TA group had the lowest inconvenience scores, with a median value of 2 in this group. There
was no evidence of a significant difference in inconvenience
between the H/C and I&C groups. The median scores for
these two groups were 4 and 3, respectively.
Patient satisfaction
There was a significant difference in satisfaction between the
H/C treatment group and each of the other two groups. The
H/C group had a median satisfaction score of 2, which was
significantly lower than the TA and I&C groups, which both
had a median score of 4.
Adverse events
None of the patients reported any adverse events such as skin
depigmentation, decreased vision from globe penetration
or significant haemorrhage following either I&C or TA
injections.
DISCUSSION
The results of this study suggest that a single transconjunctival 0.2-mL injection of 10 mg/mL of TA followed by
repeated digital massage at home, has efficacy comparable
with I&C in the treatment of chalazia and with similar patient
satisfaction and less pain and patient inconvenience.
Incision and curettage of chalazia is one of the most
common minor operations performed in ophthalmology
departments and is often a ‘one-stop’ procedure on the day of
the patient’s first outpatient visit. In practice we found that
many patients were not prepared to undergo an operative
procedure the same day, or drove to the eye clinic so could
not have their eye padded afterwards and had to rebook their
appointment for the procedure with implications on resource
management. Moreover, chalazia tend to occur in a younger
age group who may have a substantial psychological aversion
to surgery (which involves an anaesthetic injection plus the
surgical procedure) as opposed to an injection only. A Canadian survey of ophthalmologists had suggested that chalazion surgery should not be trivialized and should be treated
with the same respect as any other ocular surgery.15 Previous
studies4–7 had suggested that TA injections, although effective frequently, needed to be repeated before complete chalazion resolution is achieved. Multiple injections would
affect the convenience of and pain induced by the treatment.
Conservative treatment with H/C is unlikely to induce pain
but has a significantly lower resolution rate, and the treatment may impact on the lifestyle of the typical younger
busy/employed patient who may have difficulty in complying with the treatment.
We have attempted to quantify these elements by incorporating this into our follow-up questionnaire in asking the
711
patients about inconvenience of treatment, the experience
throughout the procedure and the subsequent recovery,
Numerical Rating Scores were used to measure these outcomes as this method was found to be superior in a previous study comparing it with the Visual Analogue Scale and
the Verbal Rating Scale.14 The study deemed the Numerical
Rating Scale to be superior in measuring outcomes such
as pain in treatment evaluative trials because of its ease of
scoring for patients, a numerical system being easy to
analyse and because it was found to yield consistent
results.
The transconjunctival route of TA injection was also
found to be safe as this route appears to avoid localized skin
depigmentation8,9 or inadvertent penetration of the globe.
Ho7 documented that two out of the 48 patients that underwent subcutaneous intralesional triamcinolone injection
were affected by localized skin depigmentation whereas in
our study, none of the 56 patients that underwent this procedure suffered this adverse effect. Our cohort consisted of
patients with a variety of skin pigmentations, of whom at
least 50% were Afro Caribbean or Asian. Therefore, this
study supports the notion that the transconjunctival route
of TA injection minimizes the risk of localized skin
depigmentation. One possible explanation for this could be
that although the injection is aimed at being deposited
intralesionally, occasionally a small portion of TA may be
deposited by the needle on the way in or out of the injection
site.
Previous studies investigating the efficacy of TA in the
treatment of chalazia have used varying concentrations of
the drug. Whereas in Ho’s study,7 the concentration of TA
used was 10 mg/mL, in Simon et al.’s study,8 a dilution of
40 mg/mL was used injected. We opted to use the lower
concentration of steroid in our study. The rationale for this is
that by using the minimal therapeutic concentration of TA,
we would minimize the risk of localized skin depigmentation
in a cohort which we expected to be multiethnic, reflecting
the local population. Indeed, an even lower concentration of
injected TA (5 mg/mL) has been reported as being efficacious
in a previous smaller study.16 Further studies investigating
how the efficacy of intralesional triamcinolone varies with
different concentrations are required to answer this important question.
The 46% baseline resolution rate in the conservative
group was consistent with previous reports of chalazia resolution without medical or surgical intervention. Resolution
of chalazia through this management option may indeed
depend on the chronicity of a chalazion before H/C are
applied. To date, there are no published surveys investigating
this.
The use of antibiotic ointment containing steroid was not
investigated as one of the treatment options in this study.
Although topical steroid ointment may theoretically penetrate the chalazia by infiltrating through the conjunctiva
into the tarsal plate, this would also inadvertently significantly increase the risk of raised IOP in a cohort of patients
whose IOP was not specifically being followed up.17
© 2007 The Authors
Journal compilation © 2007 Royal Australian and New Zealand College of Ophthalmologists
712
Goawalla and Lee
The lower pain and inconvenience levels reported by the
TA group compared with the I&C group are indicative of its
patient friendliness. The pain scores were taken 3 weeks
after the intervention in order that the postoperative/postinjection pain was included in this scoring. Unfortunately,
this may have meant that the score may have been influenced
by whether the treatment was successful.
Chalazia mimicking malignant lesions such as sebaceous
cell carcinoma have been well described but fortunately are
extremely rare.18 Although largely unknown, the effect of
injecting steroid erroneously into a sebaceous cell carcinoma
could, at worse, mask its presence leading to a delayed or
even missed diagnosis and, in turn, a disastrous clinical
outcome! Therefore, it is important to ensure that all chalazia
being considered for TA injection have no atypical features.
In addition to having a resolution rate comparable with
conventional I&C, triamcinolone injections theoretically
avoid excessive bruising of the lid as it is far less traumatic.
Not needing an eye-pad post treatment means that patients
can drive and resume their daily activities almost immediately following treatment. Intralesional triamcinolone injections for chalazia have obvious economic and practical
advantages for the health-care provider as its cost in time and
equipment is a fraction of that for conventional surgical
treatment. TA injections are therefore a good first-line treatment option for uncomplicated chalazia and could be administered by trained nurse practitioners in the eye clinic or even
in a primary health-care setting.
ACKNOWLEDGEMENT
The authors would like to acknowledge North-west London
Hospitals NHS Trust for acting as sponsors for this study.
REFERENCES
1. Donaldson MJ, Gole GA. Amblyopia due to inflamed chalazion
in a 13-month old infant. Clin Experiment Ophthalmol 2005; 33:
332–3.
2. Rumelt S, Rubin PA. Potential sources for orbital cellulitis. Int
Ophthalmol Clin 1996; 36: 207–21.
3. Perry HD, Serniuk RA. Conservative treatment of chalazia.
Ophthalmology 1980; 87: 218–21.
4. Cottrell DG, Bosanquet RC, Fawcett IM. Chalazions: the frequency of spontaneous resolution. Br Med J (Clin Res Ed) 1983;
287: 1595.
5. Pizzarello LD, Jakobiec FA, Hofeldt AJ, Podolsky MM. Silvers.
Intralesional corticosteroid therapy of chalazia. Am J Ophthalmol
1978; 85: 818–21.
6. Watson AP, Austin DJ. Treatment of chalazions with injection
steroid suspension. Br J Ophthalmol 1984; 68: 833–5.
7. Ho SY, Lai JSM. Subcutaneous steroid injection for chalazia:
prospective series. HKMJ 2002; 8: 18–20.
8. Ben Simon GJ, Huang L, Nakra T, Schwarcz RM, McCann JD,
Goldberg RA. Intralesional Triamcinolone Acetonide Injection
for Primary and Recurrent Chalazia: is it really effective? Ophthalmology 2005; 112: 913–17.
9. Ahmad S, Baig MA, Khan MA, Khan IU, Janjua TA. Intralesional corticosteroid injection vs surgical treatment of
chalazia in pigmented patients. J Coll Physicians Surg Pak 2006;
16: 42–4.
10. Kligman AM, Willis I. A new formula for depigmenting human
skin. Arch Dermatol 1975; 111: 40–8.
11. Cohen BZ, Tripathi RC. Eyelid depigmentation after intralesional injection of a fluorinated corticosteroid for chalazion. Am
J Ophthalmol 1979; 88: 269–70.
12. Nawrocki J, Swietliczko I, Nawrocka Z. Pars plana vitrectomy
following accidental injection of depot steroids into the vitreous body. Klin Monatsbl Augenheilkd 1990; 197: 519–21.
13. Schulz KF, Grimes DA. Generation of allocation sequences in
randomised trials: chance, not choice. Lancet 2002; 359: 515–19.
14. Bolton JE, Wilkinson RC. Responsiveness of pain scales: a comparison of three pain intensity measures in chiropractic
patients. J Manipulative Physiol Ther 1998; 21: 1–7.
15. Smythe D, Hurwtiz JJ, Tayfour F. The management of chalazion: a survey of Ontario ophthalmologists. Can J Ophthalmol
1990; 25: 252–5.
16. Mustafa TA, Oriafage IH. Three methods of treatment of chalazia in children. Saudi Med J 2001; 22: 968–72.
17. Lee YJ, Park CY, Woo KI. Ocular hypertensive response to
topical dexamethasone ointment in children. Korean J Ophthalmol 2006; 20: 166–70.
18. Shields JA, Demirci H, Marr BP, Eagle RC Jr, Schields CL.
Sebaceous carcinoma of the eyelids: personal experience with
60 cases. Ophthalmology 2004; 111: 2151–7.
© 2007 The Authors
Journal compilation © 2007 Royal Australian and New Zealand College of Ophthalmologists