Some eyelid lesions require injections, excision

Issue: March 2002

Although optometrists in 20 states and the District of Columbia are currently permitted to use injectable medications, these privileges come with numerous restrictions. While optometrists in all of the permitted states can use injectables to combat an anaphylactic event, fewer than 10 states allow the use of injectables for other purposes, such as steroid injection.

“In the past 5 to 10 years, optometrists in more and more states have been obtaining injection privileges,” said Gerald Melore, OD, MPH, FAAO, of the VA Medical Center Optometry Section in Fresno, Calif. “And I think all states should have injection privileges, if only for counteracting anaphylaxis. That would be in the public’s best interest.”

Other important uses of injectable medications include injections for local anesthesia necessary to incise or excise eyelid lesions such as chalazia, verrucae and sebaceous cysts.

Chalazia respond to injection

Among the lesions most commonly treated through injection are chalazia. A chalazion is a non-infectious, granulomatous inflammation of the meibomian glands. The nodule itself consists of many types of steroid-responsive immune cells, including connective tissue macrophages known as histiocytes, multinucleate giant cells, plasma cells, polymorphonuclear leukocytes and eosinophils.

According to Tammy P. Than, OD, MS, FAAO, a professor at the University of Alabama-Birmingham, chalazia are often responsive to injection.

“A chalazion that fails to respond to warm compresses and digital massage often may be managed by injecting it directly (interlesionally) with a steroid, usually triamcinolone acetonide (Kenalog 10 or 40 [10 mg/mL triamcinolone acetonide or 40 mg/mL]),” Dr. Than said. “If the chalazion is long-standing, large (>6 mm) or if the patient desires immediate results, management would include incision and curettage.”

This involves a minor surgical procedure, according to Dr. Than, in which an incision is made vertically in the palpebral conjunctiva (or horizontally if the approach is transcutaneous). The contents are then removed with a curette.

“It is recommended additionally that the sac that encapsulates the chalazion be removed with a disposable cautery unit,” Dr. Than said. “Occasionally, one or two interrupted sutures may be required.”

According to John H. Nishimoto, OD, MBA, FAAO, a professor at Southern California College of Optometry, a chalazion may result from a previous infection. “You are then left with a non-infectious material, such as a bump that will not go away unless you physically massage the area to remove the contents,” he said. “Or you would excise it or inject it.”

Dr. Melore said in his practice, he has both excised chalazia and injected them with steroids. “Often, an internal hordeolum will turn into a chalazion,” he said. “When it’s a hordeolum, it’s an infectious process, but when it becomes a chalazion, it becomes an inflammatory process.”

Dr. Melore explained that this is a crucial time to treat the chalazion. “If you can catch the chalazion immediately after it progresses from an internal hordeolum to a chalazion and inject it with a steroid, you will get a good response to the steroid,” he said. “Chalazia that have been around for a while and get large don’t respond well to a steroid injection.”

Other lesions

Several other types of lesions are routinely excised from the eyelid, according to practitioners. One such lesion is a milium, Dr. Than said.

A 1- to 2-mm whitish firm lesion commonly found on the eyelid, a milium can be removed easily and without anesthesia, Dr. Than said. “The overlying epidermis can be punctured with a 25-gauge needle, and the small keratin plug can be removed,” she said.

Another commonly excised lesion is a suderiferous cyst, which is a cyst of the gland of Möll, Dr. Than said. “This is fluid filled and can readily be drained like a blister by making a small stab incision,” she said.

Other lesions require more extensive procedures and typically require an injection of a local anesthetic, according to Dr. Than. “These include squamous papillomas, veruccae and sebaceous cysts,” she said. “Practitioners should be prepared to cauterize if excessive bleeding occurs and perhaps to place one or two interrupted sutures if the incision is large.”

Corneal foreign bodies and patching

The procedure for removing corneal foreign bodies has not changed significantly over the past few years, practitioners claim.

“Typically, the primary issue is that for most foreign bodies, one does not patch the eye,” said Dr. Nishimoto. “For years, patching was recommended, but most doctors don’t do that at all now, due to a higher risk for infection.”

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used when foreign bodies are removed. They can be prescribed for use before, during or after removal.

“You can actually do it beforehand, but I don’t know if that is really necessary, simply because, in many cases, the eye is already anesthetized,” Dr. Nishimoto said. “You can give patients a drop of NSAIDs right afterward, and then you start them on a regimen.”

Dr. Than said her use of NSAIDs varies from case to case.

“If I use an NSAID, I use it post-foreign body removal,” she said. “On the rare occasions when I pressure patch, I’ll instill a drop prior to patching. Otherwise, I’ll prescribe an NSAID based on the patient’s pain tolerance and the size of the corneal defect. Pain is very individualized, and after spending time with each patient you can usually gauge whether the patient will require pain management.”

Bandage lens vs. patching

Bandage contact lenses and, less frequently, pressure patching, may also be used.

“For patients with large abrasions that are not contact lens-related, pressure patching is still an acceptable practice,” Dr. Nishimoto said. “It is usually not desirable if you have a contact lens abrasion or if the patient sleeps in his or her contact lenses and develops an abrasion that way. In that case, you traditionally do not want to patch them, due to the high risk of infection.”

Dr. Than said she rarely uses either of these approaches. “I rarely use pressure patches anymore, and almost never for foreign body removal,” she said. “I use bandage contact lenses occasionally, but often I will do neither. The topical NSAIDs have been quite useful.”

Dr. Melore said, for the most part, bandage lenses have replaced pressure patching in foreign body removal. “Patching is still a viable method, and in some cases the only method,” he said. “But it depends on the extent of the corneal abrasion. The nice thing about a bandage lens is the fact that the patient doesn’t have to have his or her eye sealed shut, so it can still be used.”

For Your Information:

Gerald Melore, OD, MPH, FAAO, can be reached at the VA Medical Center Optometry Section, 2615 E. Clinton Ave., Fresno, CA 93703-2223; (559) 225-6100, ext. 4018; fax: (503) 241-0222.

Tammy P. Than, MS, OD, FAAO, can be reached at UAB School of Optometry, 1716 University Blvd., Birmingham, AL 35294-0010; (205) 975-5235; fax: (205) 934-6758.

John H. Nishimoto, OD, MBA, FAAO, can be reached at Southern California College of Optometry, 2575 Yorba Linda Blvd., Fullerton, CA 92831; (714) 440-7409; (714) 992-7809.