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Intralesional triamcinolone acetonide injection

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ARTICLE in INTERNATIONAL OPHTHALMOLOGY JANUARY 2014

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Intralesional triamcinolone acetonide
injection for the treatment of primary
chalazions

Michelle Y.Y.Wong, Gordon S.K.Yau,

Jacky W.Y.Lee & Can Y.F.Yuen

International Ophthalmology
The International Journal of Clinical
Ophthalmology and Visual Sciences

ISSN 0165-5701

Int Ophthalmol
DOI 10.1007/s10792-014-9904-1

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 Author's personal copy
Int Ophthalmol
DOI 10.1007/s10792-014-9904-1
ORIGINAL PAPER
Intralesional triamcinolone acetonide injection
for the treatment of primary chalazions
Michelle Y. Y. Wong Gordon S. K. Yau
Jacky W. Y. Lee Can Y. F. Yuen
Received: 6 November 2013 / Accepted: 7 January 2014
Springer Science+Business Media Dordrecht 2014
Abstract The aim of this study was to investigate the
safety and efficacy of intralesional triamcinolone ace-
tonide (TA) injection in the treatment of primary
chalazions not responding to conservative treatment.
Patient medical records were retrospectively reviewed
for all consecutive patients that received intralesional
TA injection by a single surgeon between January 2012
and March 2013 for the treatment of unresolved primary
chalazions despite 1 month of conservative treatment.
The dose of TA injection ranged from 2 to 6 mg (40 mg/
mL) depending on the size of the chalazion. The main
outcome measures included time to resolution, time to
50 % size reduction, and complications from the
treatment. During the study period, 48 chalazions from
38 patients were treated by intralesional TA injection. A
50 % reduction in size was achieved in 81.3 % of
chalazions in 4 weeks and 83 % achieved complete
resolution in 6 weeks. The mean time to complete
resolution was 15.7 10.0 days. There were no com-
plications noted from the injections; 14.6 % required
subsequent incision and curettage and 2.1 % required a
second TA injection for complete resolution. Intrale-
sional TA injection is a safe, simple, and effective
procedure for the management of primary chalazions
M. Y. Y. Wong
G. S. K. Yau (&)

J. W. Y. Lee
C. Y. F. Yuen
Department of Ophthalmology, Caritas Medical Centre,
111 Wing Hong St., Kowloon, Hong Kong Special
Administrative Region, China
e-mail: skyau0303@gmail.com
and may be considered as an alternative to incision and
curettage in cases not responding to conservative
treatment.
Keywords Chalazion
Intralesional
Steroid

Triamcinolone acetonide
Introduction
A chalazion, also known as a meibomian gland
lipogranuloma, is caused by inflammation of a blocked
meibomian gland and retained meibomian secretions.
It is benign and often self-limiting, and more com-
monly affects the upper eyelid. Patients usually
present with lid swelling, pain, and symptoms of local
irritation. However, larger lesions may be unsightly
and may lead to complications such as corneal
astigmatism, mechanical ptosis, and secondary infec-
tions [1, 2]. Treatment options for chalazions include
conservative treatment with eyelid hygiene, warm
compression, antibiotic eye ointment, and mild topical
mild steroids [35]. Occasionally, systemic antibiotics
are given for associated cellulitis. Surgical interven-
tion is considered when conservative management
fails. Surgical options include incision and curettage
(I&C), total excision, injection of triamcinolone
acetonide (TA), or carbon dioxide laser treatment
[6, 7]. I&C is a painful procedure despite local
anaesthesia and is especially high risk when per-
formed in children who are not cooperative. The
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 Author's personal copy
Table 1 Exclusion criteria
Exclusion criteria for study patients
Concurrent eyelid infection
Duration of \1 month
Absence of a palpable lid chalazion
Recurrent chalazion
Atypical features that may indicate suspicion of malignancy
History of steroid-induced raised IOP
Defaulted follow-up
purpose of this study was to investigate the safety and
efficacy of intralesional TA injection in the treatment
of primary chalazions not responding to conservative
treatment.
Patient and methods
This was a single centre retrospective case series
from a district hospital (Caritas Medical Centre) in
Hong Kong Special Administrative Region, China.
Patient medical records were reviewed for all
subjects who underwent intralesional TA injection
for a chalazion by a single surgeon (SKY) between
January 2012 and March 2013. The inclusion criteria
included consecutive subjects with the diagnosis of
chalazion who consented for intralesional TA injec-
tion after failed conservative treatment with lid
hygiene, warm compression, and antibiotic ointment
(Chloramphenicol 1 %; Shanghai Sunway Pharma-
ceutical Technology Co., Ltd., Shanghai, China)
three times per day for at least 1 month. Exclusion
criteria are shown in Table 1. Informed consent was
obtained before the procedure. Ethics approval by
the Hospital Authority of Hong Kong was obtained
for this study.
Fig. 1 Left patient with left
upper eyelid chalazion.
Right complete resolution
8 days after 4 mg (0.15 mL)
TA injection
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Int Ophthalmol
Data regarding duration of symptoms as well as the
size (length 9 width in millimetres) and location of
the chalazion(s) were documented by digital coloured
photographs of the chalazion(s) taken at every visit
(Figs. 1, 2). Visual acuity, intraocular pressure (IOP)
by Goldmann applanation tonometry, and a complete
ophthalmological examination were performed before
the injection was given.
Technique for triamcinolone injection
All subjects underwent the same technique for TA
injection. Children \8 years were sedated with oral
chloral hydrate (50 mg/kg) 30 min before the proce-
dure [8]. Topical anaesthesia (proparacaine 0.5 %)
eye drops were instilled in the affected eye before the
injection. TA ranging from 0.05 to 0.15 mL (40 mg/
mL) (Stacort-A; Standard Chem & Pharm Co., Ltd,
Tainan City, Taiwan) according to the size of the
lesion was injected intralesionally in the out-patient
treatment room (Table 3). The eyelid was inverted and
the TA was injected transconjunctivally into the centre
of the lesion with a 27-gauge needle. When it was not
possible to evert the eyelid due to extensive swelling,
the injection was given transcutaneously into the
chalazion after disinfection of the skin with 70 %
isopropyl alcohol wipes. No patching was required
after the procedure. The patients were given chloram-
phenicol 1 % eye ointment three times per day to
apply over the lesion and advised to continue warm
compression 46 times per day for 10 min with a
hardboiled egg.
The patients were reviewed every 2 weeks after the
TA injection until resolution of the chalazion. The
chalazion was measured clinically (length 9 width) in
millimetres. Failure was defined as an absence of
maximal chalazion diameter reduction at 2 weeks
 Author's personal copy
Int Ophthalmol

Fig. 2 Left patient with

right lower eyelid chalazion.
Right complete resolution
12 days after 4 mg
(0.15 mL) TA injection

Table 2 Patient demographics of 26.2 19.4 years (range 276 years). Patient
Characteristics Value
demographics are summarised in Table 2.
The mean duration of the chalazion before the
Number of patients 38 intralesional TA injection was 2.3 2.5 months.
Number of chalazions 48 There were 45.8 % (22/48) of chalazions \1 cm in
Gender diameter, 52.1 % (25/48) of chalazions between 1 and
Male 20 (53 %) 1.5 cm in diameter, and 2.1 % (1/48) of chalazions
Female 18 (47 %) [1.5 cm in diameter. They were given an intralesion-
Age 276 al TA injection of 2, 4, and 6 mg, respectively, without
Location any complications or raised IOP noted after the
RUL 9 procedure.
RLL 19 Seventy-seven percent (37/48) of chalazions
LUL 15 achieved complete resolution within 4 weeks post-
LLL 5 injection and 83.3 % (40/48) of chalazions achieved
Size (maximal diameter) complete resolution within 6 weeks. Seventy-seven
\1 cm 22 percent (37/48) of chalazions achieved a 50 % size
11.5 cm 15 reduction at 2 weeks and 81.3 % (39/48) of chalazions
[1.5 cm 1 achieved the same result by 4 weeks.
In total, 14.6 % (7/48) of chalazions failed to
RUL right upper lid, RLL right lower lid, LUL left upper lid,
LLL left lower lid reduce in size by 2 weeks and underwent secondary
I&C and 2.1 % (1/48) of chalazions received a second
TA injection and achieved complete resolution
after the TA injection. Failure cases were offered I&C 2 weeks after the second injection. The majority of
or a second intralesional TA injection. Main outcome failed cases had chalazions with a diameter between 1
measures included the size of the chalazion during and 1.5 cm (Table 3). One case requiring I&C had a
each follow-up interval, time taken for a 50 % chalazion size \1 cm. The mean time to complete
reduction in the size of the chalazion, time taken for resolution was 15.7 10.0 days.
complete resolution, and complications from the
procedure. All means were expressed as mean stan-
dard deviation. Discussion

Chalazions are a commonly encountered eye problem

Results
During the study period, 48 primary chalazions in 38
patients were treated with intralesional TA injections.
All patients were of Chinese ethnicity with a mean age
due to blockage of the meibomian glands. Previous
studies have shown that 2980 % of chalazions
resolved with conservative treatment alone [912].
The results of our study suggest that intralesional TA
injection was an effective and safe treatment modality

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Table 3 Dosage of intralesional TA injection and outcome of treatment according to size of lesion
Dosage of intralesional TA injection (mg/mL)
Distribution by size of chalazion (%)
Percentage of chalazions that resolved after a single TA injection (%)
Percentage of chalazions that require secondary I&C (%)
Percentage of chalazions that required a second TA injection (%)
Time taken to complete resolution (days)
for primary chalazions not responding to conservative
treatment. Complete resolution of the chalazion was
achieved in 83.3 % of treated lesions at a mean of
15.7 10.0 days. A single injection was sufficient in
most cases and only one case required a second
injection.
Our regimen of titrating the volume of TA injection
according to the size of the lesion appears to be
effective for chalazions \1.5 cm. For chalazions
\1 cm, 2 mg of TA was effective and resulted in
complete resolution in 95.5 % of chalazions. For
larger lesions between 1 and 1.5 cm, 72 % of chalaz-
ions achieved complete resolution with a single TA
injection of 4 mg. It seems that chalazion size at
presentation was an important determinant of success
for TA injection, with larger lesions more likely to
need subsequent I&C or a second TA injection. Our
findings are consistent with those of Palva and
Pohjanpelto who reported that larger lesions were
associated with a lower rate of resolution by intrale-
sional corticosteroid injection and a high rate of
recurrence [12]. However, in our series, one chalazion
[1.5 cm had complete resolution after a single TA
injection although there were no other chalazions of
this diameter to allow us to draw solid conclusions
about the success of TA in such large lesions.
An intralesional steroid injection offers the advan-
tage of a quick, simple, and less painful procedure
compared to I&C. In the younger age group, apart
from the psychological aversion to surgery, it may be
difficult to perform I&C as they may not be able to
cooperate, and sometimes general anaesthesia is
necessary. Comparatively, I&C is a longer procedure
that requires injection of local anaesthesia and may be
associated with more complications such as pain,
bleeding, and scarring. In addition, patching of the eye
is often necessary after the procedure. On the other
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Int Ophthalmol
\1 cm 11.5 cm [1.5 cm
(n = 22) (n = 25) (n = 1)
2/0.05 4/0.1 6/0.15
45.8 52.1 2.1
95.5 72.0 100 (only 1 case)
4.5 24.0 0
0 4.0 0
16.1 10.8 18.3 10.1 14.0
hand, an intralesional TA injection is a procedure that
requires minimal facilities and time, and can be
performed in eyes with multiple chalazions as well as
on lesions that are close to the lacrimal punctum with
minimal risk of damaging the adjacent eyelid
structures.
Our success rate (83 %) was similar to earlier
studies that reported success rates of 6292 % after
intralesional steroid injections for chalazions [1122].
One of the earliest studies by Watson and Austin in
1984 found that 77 % of chalazions resolved with a
0.22-mg injection of steroid suspension compared to
90 % in the I&C group [14]. Since then, various
publications have affirmed a similar success rates
between intralesional steroid injection (8084 %) and
I&C (8789 %), with a slightly higher success rate in
the latter [1115]. More recently, however, Simon
et al. [16, 17] reported a higher success rate with a
4-mg intralesional TA injection (81 %) compared to
I&C (79 %).
Regarding time taken for resolution, Pavicic-Asta-
los et al. [18] found that 95 % of chalazions decreased
in size by 80 % with no recurrence after an intrale-
sional TA injection of 48 mg, with a mean time to
resolution of 15.27 days, which is comparable to our
findings (15.7 10.0 days).
Regarding the route of administration, TA injec-
tions can also be performed subcutaneously, outside
the lesion. Ho and Lai described the use of a 2-mg
subcutaneous TA injection in which 54.2 % of treated
chalazions resolved completely with one injection,
and 35.4 % resolved after two injections [23]. In their
series, two patients developed skin depigmentation at
the site of the injection. Similarly, Chung et al. [24]
found that 93.8 % of treated chalazions achieved
complete resolution with a 3-mg subcutaneous TA
injection.
 Author's personal copy
Int Ophthalmol
We did not encounter any complication from the
intralesional TA injections. Reported complications
include yellow deposits at the site of injection [19],
raised IOP, and skin hypopigmentations [2325].
More serious adverse events include inadvertent globe
penetration, traumatic cataract [26], microembolisa-
tion, and infarction of retinal and choroidal vascula-
ture [27].
Our study had limitations. It was retrospective in
nature and represented only a single centre. The
treatment modality was not randomised and there was
no control group. Furthermore, the population con-
sisted mainly of small and medium-size lesions with
only one case with a chalazion[1.5 cm. Nevertheless,
we have demonstrated that a single intralesional
injection of TA through a transconjunctival approach,
with dose titration according to lesion size, was able to
achieve complete resolution in 83 % of treated
chalazions in 16 days. TA injections may be a simple,
safe, and effective treatment alternative for primary
chalazions that do not respond to conservative
treatment.
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