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Abstract

We thank Drs Papalkar and Francis for their comments regarding our report. The lack of prospective studies comparing natural history, steroids, and incision and curettage and the fact that “in Australia, primary treatment of chalazia with intralesional steroids was abandoned by the 1990s” do not imply that steroids do not work. In our experience, they do work effectively, and rarely do we need to perform incision and curettage for chalazia. Obviously, when we suspect the lesion to be more than a simple chalazion, we perform incisional biopsy to rule out sebaceous gland carcinoma.In our view, Figure 2 demonstrates near complete (>80%) resolution of the chalazion, the lower lid is not erythematous, and there is very mild swelling of the upper eyelid. Practically speaking, we consider this to be complete resolution. In our Figure 3, the lesion has clearly regressed, but because there is mild swelling and redness on the eyelid margin, this was considered as partial (<50%) remission.It is possible that injecting steroids with the chalazion clamp in situ may decrease the risk of steroid embolus. This is an extremely rare potential complication; to the best of our knowledge, there has been only one case report of vascular occlusion after steroid injection to chalazion.1Thomas E.L. Laborde R.P. Retinal and choroidal vascular occlusion following intralesional corticosteroid injection of a chalazion.Ophthalmology. 1986; 93: 405-407Abstract Full Text PDF PubMed Scopus (70) Google Scholar Application of the clamp requires anesthesia and substantially decreases the appeal of an otherwise minimally invasive nonsurgical approach.An important issue that is not discussed in the letter is the patient’s perception of incision and curettage as a surgery as opposed to a more simple treatment given in the form of injection. In our experience, many patients are seeking a nonsurgical treatment, and are delighted to avoid “surgery.” Triamcinolone acetonide (TA) injection is also less time consuming than incision and curettage, and patients are more likely to accept additional injections rather than surgeries in the case of treatment failure.We did not analyze the actual size of the chalazia, and it may be that larger lobulated lesions had a lower success rate. Similarly, we did not record the total dose of TA (4 or 8 mg), although most injections included 0.1 ml or 4 mg; we agree with Papalkar and Francis that this may be a potential confounder in our study.It is true that incision and curettage do very well for young, liquid chalazia, and TA has an antiinflammatory effect on the granuloma of the chalazion; however, as we pointed out in our report, TA does very well also for young liquid chalazia. Triamcinolone acetonide injection was given after topical anesthesia eyedrops and 4% lidocaine solution on a cotton swab. Most patients do not describe any significant discomfort. In our experience, surgery is more likely to be associated with pain or discomfort, and in most cases, it requires an eye patch for several hours or even longer.Drs Papalkar and Francis may be correct when they comment on injections performed by nonophthalmologists. Regarding the rise in intraocular pressure, this was not noted in our study and is not, to our knowledge, typically associated with eyelid or orbital steroid injections.The purpose of the study was to examine in a retrospective fashion the efficacy of TA injection in primary and recurrent chalazia. Clearly, the study is limited in power, and as we pointed out, “In the absence of a control group in the current study, it is important to emphasize that our guidelines merely represent our clinical experience, and the efficacy of TA injection versus spontaneous remission cannot be evaluated.” Prospective studies comparing incision and curettage, steroid injection, and natural history would provide more powerful data to clarify the role of each treatment modality. We thank Drs Papalkar and Francis for their comments regarding our report. The lack of prospective studies comparing natural history, steroids, and incision and curettage and the fact that “in Australia, primary treatment of chalazia with intralesional steroids was abandoned by the 1990s” do not imply that steroids do not work. In our experience, they do work effectively, and rarely do we need to perform incision and curettage for chalazia. Obviously, when we suspect the lesion to be more than a simple chalazion, we perform incisional biopsy to rule out sebaceous gland carcinoma. In our view, Figure 2 demonstrates near complete (>80%) resolution of the chalazion, the lower lid is not erythematous, and there is very mild swelling of the upper eyelid. Practically speaking, we consider this to be complete resolution. In our Figure 3, the lesion has clearly regressed, but because there is mild swelling and redness on the eyelid margin, this was considered as partial (<50%) remission. It is possible that injecting steroids with the chalazion clamp in situ may decrease the risk of steroid embolus. This is an extremely rare potential complication; to the best of our knowledge, there has been only one case report of vascular occlusion after steroid injection to chalazion.1Thomas E.L. Laborde R.P. Retinal and choroidal vascular occlusion following intralesional corticosteroid injection of a chalazion.Ophthalmology. 1986; 93: 405-407Abstract Full Text PDF PubMed Scopus (70) Google Scholar Application of the clamp requires anesthesia and substantially decreases the appeal of an otherwise minimally invasive nonsurgical approach. An important issue that is not discussed in the letter is the patient’s perception of incision and curettage as a surgery as opposed to a more simple treatment given in the form of injection. In our experience, many patients are seeking a nonsurgical treatment, and are delighted to avoid “surgery.” Triamcinolone acetonide (TA) injection is also less time consuming than incision and curettage, and patients are more likely to accept additional injections rather than surgeries in the case of treatment failure. We did not analyze the actual size of the chalazia, and it may be that larger lobulated lesions had a lower success rate. Similarly, we did not record the total dose of TA (4 or 8 mg), although most injections included 0.1 ml or 4 mg; we agree with Papalkar and Francis that this may be a potential confounder in our study. It is true that incision and curettage do very well for young, liquid chalazia, and TA has an antiinflammatory effect on the granuloma of the chalazion; however, as we pointed out in our report, TA does very well also for young liquid chalazia. Triamcinolone acetonide injection was given after topical anesthesia eyedrops and 4% lidocaine solution on a cotton swab. Most patients do not describe any significant discomfort. In our experience, surgery is more likely to be associated with pain or discomfort, and in most cases, it requires an eye patch for several hours or even longer. Drs Papalkar and Francis may be correct when they comment on injections performed by nonophthalmologists. Regarding the rise in intraocular pressure, this was not noted in our study and is not, to our knowledge, typically associated with eyelid or orbital steroid injections. The purpose of the study was to examine in a retrospective fashion the efficacy of TA injection in primary and recurrent chalazia. Clearly, the study is limited in power, and as we pointed out, “In the absence of a control group in the current study, it is important to emphasize that our guidelines merely represent our clinical experience, and the efficacy of TA injection versus spontaneous remission cannot be evaluated.” Prospective studies comparing incision and curettage, steroid injection, and natural history would provide more powerful data to clarify the role of each treatment modality. Injections for Chalazia?OphthalmologyVol. 113Issue 2PreviewWe were intrigued to read Ben Simon et al’s article in the May 2005 issue.1 Interestingly, one of us (ICF) is old enough to have been around and managing chalazia when the last wave of popularity struck in terms of their management with intralesional steroid as the primary modality of treatment.2 This was in the mid-1980s, and much like any treatment in medicine, the maxim was followed that “You had better use/do the treatment/drug/operation soon, before you find out that it doesn’t actually work.” In Australia, primary treatment of chalazia with intralesional steroids was abandoned by the 1990s. Full-Text PDF