# Meibomian Cyst (Chalazion) Incision & Drainage

## Overview

This module describes how to incise and drain a Meibomian cyst (chalazion).

## Indications

1. Meibomian cyst with failure of

   conservative measures
   conservative measures

   Instruct the patient to perform twice daily warm compresses (3–5 minutes) and massage (either with fingers or cotton tips) to assist in the release of the chalazion contents. The direction of the massage should be over the lesion, in the direction of the eyelashes.

## Contraindications

1. Uncooperative patient

2. Large meibomian cysts obscuring vision

3. In the elderly, where malignancy is suspected

## Patient information and consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“There is a small swelling on your eyelid because of a blocked gland. We call this a Meibomian cyst. It is necessary to remove it because it can get bigger or become infected.”

### What can my patient expect?

“I will place drops in your eye to numb the eyeball and then put a small injection in the eyelid to numb the eyelid. After that I will turn your eyelid inside out, which will not be painful and not too uncomfortable. I will then place an instrument to shield your eye and make a small cut in the eyelid to drain the cyst.”

### What is my patient’s role?

“Let me know if you have any allergies, a heart condition, or a bleeding tendency, or use blood thinners. Fearing blood or needles is normal, but tell me if you have fainted from it. Please look up while I instil the drops and while I put the injection into the eyelid. After that, please try to remain very still during this procedure.”

## Preparation

###

### Documentation

1. Patient notes

### Equipment

1. Sterile gloves
   Sterile gloves

   Although it is considered best practice to use sterile gloves to perform minor procedures, there is mounting evidence that infection rates are similar for sterile and non-sterile glove use.

2. Alcohol-based hand rub

3. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

4. A surgical or waterproof marker

5. A 3-5 ml syringe, aspiration needle (ideally blunt fill), and a small injection needle

6. Lignocaine 1% without adrenaline

7. An alcohol swab

8. Topical anaesthetic
   Topical anaesthetic

   kept in the fridge

   (0.5% proparacaine eye drops)

9. Dressing pack

10. Aqueous povidone iodine 5%

11. Eye drape (optional)

12. Chalazion clamp
    Chalazion clamp

13. #11 blade

14. Scalpel handle (optional)

15. Small curette

16. Fine toothed forceps (required if removing pseudocapsule)

17. Fine scissors (required if removing pseudocapsule)

18. Cautery (preferable but not always required)

19. Antibiotic ointment (eg. chloramphenicol 1%)

20. Two eye pads

21. Tape (eg. micropore)

## Site & Positioning

The patient can be seated in front of you, facing forward with the head preferable against the wall, but it is easier and safer if the patient is lying on a bed facing the ceiling. Always position good lighting on the site, and

magnification

magnification

Use a magnifier, magnifier with light or a loupe. If not available, one can use a pair of +2:00 reading glasses. Readers are useful because it leaves your hands free to perform the procedure.

can be useful.

## Procedure

Follow medical asepsis with sterile gloves.

1. Perform hand hygiene.

2. Locally anaesthetise the eye by instilling topical anaesthetic drops into the eye.

3. Draw the outline around the lesion with the marker.

4. Open the suture pack to create a sterile field and pour skin disinfectant into the well. Open the needles & syringe, clamp, curette, forceps, scissors, scalpel blade and dressing onto the sterile field.

5. Perform hand hygiene and don gloves.

6. Apply

   aqueous povidone iodine
   aqueous povidone iodine

   Avoid alcohol based cleaning solutions, because it can cause corneal epithelial damage.

   5% preparation to the eye and lids and drape the site.

7. Ask an assistant to clean the rubber top with an alcohol swab and hold up a bottle of lignocaine without adrenaline. Draw up 2-3 ml. Put the chalazion clamp under the eyelid (between the lid and the eye) to protect the globe against accidental penetration, and infiltrate lignocaine into the

   subcutaneous tissue
   subcutaneous tissue

   To avoid penetrating the globe, infiltrate just below the skin surface and ask the patient to look away from the injection site. Smaller chalazia can be marked cutaneously with a waterproof marker before infiltration to ensure they can be readily located as injection of local anaesthetic distorts the anatomy.

   surrounding the chalazion.

8. Insert the chalazion clamp with the ring on the tarsal conjunctival side and the solid part of the clamp on the skin side of the eyelid.

9. Tighten
   Tighten

   If the patient can feel pain from the clamp, further infiltration of local anaesthetic may be required.

   the clamp to restrict bleeding, and evert the eyelid to present the conjunctival surface . Take care not to injure or damage the skin or conjunctiva (if the clamp is tightened too much).

10. Identify the blocked Meibomian gland on the tarsal surface.

11. Using a #11 blade, make a vertical incision perpendicular to the lid margin into the bulk of the chalazion contents on the

    tarsal conjunctival surface
    tarsal conjunctival surface

    If a horizontal incision is made, adjacent Meibomian glands will be damaged. Take care not to involve the lid margin or to penetrate the eyelid to the other side as this will result in scarring.

    Most chalazions will be drained through the tarsal conjunctiva.
    Only an abscess will be drained through the skin.

    of the eyelid.

12. Use a small curette to scrape out the contents of the chalazion.

13. If a

    fibrous wall or pseudocapsule
    fibrous wall or pseudocapsule

    Usually only found in large or chronic cysts. Send the capsule for histology to exclude a malignancy.

    When excising, take care not to remove too much of the tarsal tissue, resulting in scarring.

    is identified, use the forceps to grasp and then gently excise this tissue using the scissors.

14. Once the excision is complete, release the clamp. Control any bleeding with direct tamponade, or, if necessary, cautery.

15. Apply chloramphenicol ointment 1% and a firm double pad to the eye. Instruct the patient to remove the eye pads after 4 hours.

16. Further instruct the patient to use lid cleaning including hot compression, massage and scrubs in order to reduce recurrence.

17. Dispose of medical waste safely.

18. Document completion of the procedure in patient notes.

## Troubleshooting

The patient feels pain from the clamp.

More infiltration of local anaesthetic is required.

I do not have a chalazion clamp.

Continue conservative treatment until one can be procured, or refer the patient on conservative treatment.

## Risks

1. Vasovagal response (fainting)

2. Globe perforation

3. Canalicular trauma

4. Haemorrhage

5. Infection

6. Lid notching from incision to lid margin

7. Sharps injury to healthcare personnel

8. Scarring of the eyelid

## References

1. Gilchrist H, Lee G. Management of Chalazia in General Practice. Australian Family Physician. 2009 May; 38(5):311-314. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499889/

2. Jordan G, Beier K. Chalazion. [Updated 2021 Aug 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.racgp.org.au/download/Documents/AFP/2009/May/200905gilchrist.pdf

3. Pons J. How to treat the eye. In: Mash B, Blitz-Lindeque J, eds. South African Family Practice Manual. 2nd ed. Pretoria: Van Schaik Publishers; 2010:138-139