May 2019


Pulse of Ophthalmology
How are we treating chalazia?

by Mitchell Gossman, MD

“[Patients] want something done and are anxious about surgery. Anything worth doing is worth doing right, with maximum comfort and cure rate.”

During a busy day of handling serious eye disease, cataract evaluations, and glaucoma follow up, you see a patient with a painless lump of the eyelid—another chalazion.
For the patient it is a concern. They want something done and are anxious about surgery. Anything worth doing is worth doing right, with maximum comfort and cure rate.
So how are we all doing surgery for the lowly chalazion?
A survey was conducted of 88 ophthalmologists who volunteered to participate from
the ranks of participants of the ASCRS EyeConnect online community, plus volunteers in North America and worldwide. Responses are anonymous to encourage candor. Totals may not equal 100% due to rounding.
The first question was, “What anesthetic do you use?” The responses were:

Epinephrine helps with hemostasis, delays clearing of anesthetic, and is used by the majority. Bupivacaine is longer acting but is deemed by 100% to be unnecessary.
The second question was, “Do you usually inject local anesthetic subcutaneously, subconjunctivally, or both for the typical internal chalazion?” The answers were:

Subcutaneous injection is easier to administer given the easy spreading of tissues but may not provide adequate anesthesia for internal chalazia. However, injecting under the palpebral conjunctiva can be challenging because of the tough tarsus. My own practice is to start subcutaneously and if necessary augment with some subconjunctival anesthetic.
The third question was, “How do you make your incision through the tarsus?” The answers were:

Steven Safran, MD, uses the Ellman. “You have total control of your incision size, less bleeding, and can make multiple entries with the tip looking for a pocket. Then you can use the same tip to cauterize,” he said.
The fourth question was, “Do you use a chalazion clamp for adults, and if so what style?” Respondents said:

The chalazion clamp offers stabilization, hemostasis, pressure to encourage egress of material, and the plate protects the other side where the outer lamella of the lid and the globe are.
The fifth question was, “Do you sometimes use intralesional steroid (such as triamcinolone acetonide) instead of surgery?”

Some chalazia are better addressed by an intralesional steroid, which can suppress inflammation and be curative. I use intralesional steroid by itself in cases of a marginal chalazion, one in the vicinity of a canaliculus, a diffuse one, very small ones, or when there are more than two. I have used it in patients who have an important event coming and prefer not to endure the worse bruising and swelling of incisional surgery but want to do something.
The sixth question was, “Do you sometimes use intralesional 5-FU instead of surgery?

The seventh question was, “Do you sometimes use intralesional steroid plus 5-FU instead of surgery?”

The eighth question was, “Do you sometimes augment surgery with an intralesional steroid or 5-FU injection?”

I augment surgery with intralesional steroid for cases where there is considerable inflammation or a disappointing yield of lipogranulomatous material.
The ninth question was, “Do you prescribe topical drops after surgery?”

Being an inflammatory rather than infectious condition I normally do not use postoperative drops, but since an incision is made, an argument could be made for prophylaxis with antibiotic. I never use postop drops and have never had a problem.
The tenth question was, “If the contents appear to be the typical lipogranulomatous material, do you always send it for pathologic examination anyway to make sure it’s benign?”

One reason not to send a specimen with low chance of cancer is the cost. Reasons to consider sending a specimen would be recurrent chalazion, unusual features such as a yellow discharge, notable firmness, no material presenting from the incision, severe distortion of tissue, older patient, and destruction of lashes.
I hope this article has helped you reflect on how to manage this common condition and can lift some of the boredom classically associated with it.


How are we treating chalazia? How are we treating chalazia?
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