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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