Hordeolum/chalazion

Question 1

Hordeoulum

Answer 1

– Painful and infected lesion
– Associated with blepharitis
– External (zeis) vs internal (meibomian)

Question 2

Sebaceous cell carcinoma

Answer 2

– Often mistaken for recurrent chalazion in the same location
– Associated with madarosis, rapid growth, and acute onset
– High chance of metastasis
• 27% of patients with diagnosed lesion had metastasis

Question 3

BCC

Answer 3

– Most common eyelid malignancy (90%)
• Lower lid, eyelid margin, nasally *** – Ulcerated, raised, pearly borders
– Associated with madarosis
– Rarely metastatic

Question 4

SCC

Answer 4

– 2nd most common eyelid malignancy
– Variable presentations
• Nodular, irregular rolled edges, centralized ulceration
– Associated with madarosis

Question 5

Molluscum contagiosum

Answer 5

– Viral in nature

– Waxy, nodular appearance with central umbilication

Question 6

Epidermis inclusion cyst

Answer 6

– Benign lesion filled with keratin
– Congenital or acquired
– Typically form at a site of prior trauma

Question 7

Dermatitis and insect bite

Answer 7

– Moderate pruritus, edema, and erythema

Question 8

Documented detailed case history for hordeolum

Answer 8

– ROS/Allergies to medications/current medications
– History of cancer? If so, what type? How long ago? Treatment?
– Onset and change/growth over time (if any)?
– Location?
– ABCD (asymmetry, borders, color, diameter)?
– Unusual characteristics like bleeding, ulceration, pain?

Question 9

Risk assessment for malignancy

Answer 9

Send to oculoplastic
• High suspicion of malignancy
• 1+ ABCD
• 1+ unusual characteristics
• Located in medial canthus on lid margin
• Age >55
• Enlarged lymph node on ipsilateral side of lesion

Question 10

Measurement of chalazion

Answer 10

– Length, width, height

– Location

Question 11

Assessment before chalazion

Answer 11

Lymph nodes

Question 12

Ancillary testing for chalazion

Answer 12

Photography

Question 13

Other things that need done before working on chalazion

Answer 13

• Informed consent
• Bloodpressure/pulse
• Visual acuity

Question 14

Treatment options for chalazion

Answer 14

– Conservative/palliative care
– Intralesional steroid injection
– Incision and curettage

Patient must be educated on all options

Question 15

Conservative palliative care for chalazion

Answer 15

– Hot compresses QID x 6 weeks
• Rice & sock, boiled eggs, bruder hydrating masks
– Lid scrubs
– Doxycycline 50mg BID x 30 days

Question 16

Success of conservative treatment for chalazion

Answer 16

50% effective

More time consuming

Question 17

Indications for conservative care for chalazion

Answer 17

• Typically first line treatment
• <6mm lesion size
• Lesion located near punctum
• Patient choice

Question 18

Contraindications for conservative care for chalazion

Answer 18

Doxy if patient cannot tolerate/alelergic

Question 19

Risk/complications for conservative care for chalazion

Answer 19

Treatment failure

Drug sensitivity

Question 20

Intralesional steroid injection for chalazion

Answer 20

– Injection of triamcinolone acetonide (Kenalog) directly into the lesion
– About 25% of the time it requires two injections
• Within 2-6 weeks of one another

Question 21

Success of intralesional steroid injection

Answer 21

75-90% effective

Question 22

Indications for intralesional steroid injection

Answer 22

• Failure of conservative method
• Lesion located near punctum
• Patient choice

Question 23

Contraindications for intralesional steroid injection

Answer 23

• Steroid if patient cannot tolerate/allergic
• Darkly pigmented skin color
• Chronic lesions lasting >6-8 months

Question 24

Risk complications for intralesional steroid injection

Answer 24

• Infection
• Bleeding
• Bruising
• Allergic reaction
• Depigmentation of lesion
• No resolution (even with 2 injections)
• Recurrence
• Local fat atrophy
• Vision loss

Question 25

Incision and curettage for chalazion

Answer 25

– Surgical intervention with incision and drainage of lesions – Often after conservative measures do not relieve the chief complaint

Question 26

Success for incision and curretage

Answer 26

>90% effective

Question 27

Indications for incision and curettage

Answer 27

* >6mm or chronic >6-8 months * Conservative or injection treatment did not resolve lesion * Patient choice

Question 28

Contraindications for incision and curettage

Answer 28

* Allergy/sensitivity to local anesthetic * Unable to hold still * Lesion located medially near punctum

Question 29

Risk and complications for incision and curettage

Answer 29

* Infection * Bleeding * Bruising * Allergic reaction to anesthetic * Incomplete removal of lesion * Scarring * Recurrence * Lid notching * Permanent gland damage

Question 30

Equipment for intralesional steroid injection

Answer 30

``` – Alcohol and betadine swabs – Kenalog 10-40mg/mL – 1cc syringe – 25 or 27 gauge needle (1/2 inch length) – Topical anesthetic (4% lidocaine) – Sterile gauze 4”x4” – Cotton tip applicators – Chalazion clamp – Sharps ```

Question 31

Pre op for intralesional steroid injection

Answer 31

– Prep lesion with alcohol – Apply lidocaine 4% with wick cell sponge for 30 seconds – Apply betadine (especially if external injection entry) (wait 3 minutes)

Question 32

Procedure for external intralesional steroid injection

Answer 32

• Inject at an angle tangential to the globe • Stabilize hand onpatient’s face – Inject 0.2-0.4cc of 10-20mg/mL – Apply pressure with gauze for 2-3 minutes (blood in tears) – Apply erythromycin ung in office

Question 33

Intralesional steroid injection for internal chalazion

Answer 33

• Evert eyelid with clamp • Inject at an angle tangential to globe • Stabilize hand onpatient’s face – Inject 0.2-0.4cc of 10-20mg/mL – Apply pressure with gauze for 2-3 minutes (blood in tears) – Apply erythromycin ung in office

Question 34

Post op for intralesional steroid injection

Answer 34

– Rx Erythromycin ung BID x 3-5 days – Resume hot compresses in 2-3 days – RTC 2-4 weeks for evaluation of resolution Reimbursement is $47.86

Question 35

Equipment for incision and curettage

Answer 35

– Alcohol and betadine swabs – 1-3cc syringe – 27 or 30 gauge needle (1/2 inch length) – Local anesthetic (Lidocaine 1% w/w/o epinephrine 1:200,000) – Topical anesthetic (lidocaine 4%) – Sterile gauze 4”x4” – Cotton tip applicators & wick cell sponges – Chalazion clamp and curette – 11 or 15 blade scalpel – Erythromycin ung – Sharps

Question 36

Procedure for incision and curettage

Answer 36

– Apply smallest possible chalazion clamp → evert lid • No slippage but without crushing (PAIN) – Vertical incision • Cut away from globe (towards lid margin) • Stop 2-3mm from lid margin – Removal capsular contents with curette – Fibrotic capsule: Excise fibrotic capsule with forceps and Wescott scissors: cut “X” and snip corners – Injection intralesional steroid (optional) – Pressure 3 minutes → hemostasis – Palpate for completion – Apply pressure dressing (PRN)

Question 37

Post op for incision and curettage

Answer 37

– Rx Erythromycin ung QID x 7 days – Resume hot compresses in 2-3 days – RTC 1-4 weeks for evaluation of resolution