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CASE REPORT
Year : 2015  |  Volume : 7  |  Issue : 2  |  Page : 64-66

Eyelid gangrene and endophthalmitis after Chalazion surgery: About a case


1 Department of Ophthalmology, University Hospital of Brazzaville, Brazzaville, Congo
2 Medical department (Dermatology Unit), Talangaļ Hospital, Brazzaville, Congo

Date of Web Publication12-Nov-2015

Correspondence Address:
Pepin Williams Atipo-Tsiba
Department of Ophthalmology, University Hospital of Brazzaville
Congo
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DOI: 10.4103/1858-540X.169440

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  Abstract 

A chalazion is caused by an obstruction of excretion channel of the meibomian gland due to the accumulation of its own secretions. It can be ovoid, lobed, but most often it is a round nodule, variable in size, usually painless. Conservative treatment is the rule. When this fails, surgery is the only alternative, especially for nodules located far from the inner canthus due to the risk of seeing the section of lacrimal organs. This surgery is simple, with local anesthesia in adults and sometimes general anesthesia in children. It is exceptionally the cause of complications that can compromise the visual and/or vital prognosis. We have only found three cases in the literature, one apex orbital syndrome, an eyelid necrosis and one severe orbital bleeding. This observation reports a case of an eyelid gangrene associated with endophthalmitis due to Pseudomonas aeruginosa, which occurred after surgery for Chalazion in a healthy patient.

Keywords: Chalazion surgery and serious complications, gangrene and endophthalmitis, Pseudomonas aeruginosa infection


How to cite this article:
Atipo-Tsiba PW, Bayonne ES. Eyelid gangrene and endophthalmitis after Chalazion surgery: About a case. Sudanese J Ophthalmol 2015;7:64-6

How to cite this URL:
Atipo-Tsiba PW, Bayonne ES. Eyelid gangrene and endophthalmitis after Chalazion surgery: About a case. Sudanese J Ophthalmol [serial online] 2015 [cited 2019 May 21];7:64-6. Available from: http://www.sjopthal.net/text.asp?2015/7/2/64/169440


  Introduction Top


Chalazion or  Meibomian cyst More Details is caused by a blockage of the excretory duct of the meibomus' gland. Chronic blepharitis, rosacea, and seborrheic dermatitis are the major contributing known factors. It is a rounded eyelid nodule, variable in size, usually painless. [1] Conservative treatment, application of warm compresses with or without corticosteroid ointment and sometimes an intralesional injection of triamcinolone diacetate, is the rule. When this fails, surgery is the only alternative, especially for nodules located far from the inner canthus due to the risk of seeing the section of lacrimal organs. [1],[2] This surgery is exceptionally the cause of complications that can compromise the visual and/or vital prognosis. Some factors might explain the severity of these complications when they occur. The rich vascularization of the eyelid (many anastomoses) may aggravate an infection by the rapid spread of the germ. It may also, in case of vascular injury, cause an important orbital bleeding requiring cantholysis. [3] This is exceptional, but it was reported to genuine cases of eyelid necrosis associated with the use of local anesthesia. [4] This observation reports a case of an eyelid gangrene associated with endophthalmitis due to Pseudomonas aeruginosa, which occurred 5 days after surgery for Chalazion in a healthy 30-year-old patient.


  Case report Top


The patient was seen for a small (the size of a pea) painless Chalazion of the left upper eyelid located at 3 mm from the "gray line" on the median which divided the eyelid into two equal portions. The visual acuity (left eye) was 10/10, cornea was normal. It was a second recurrence after treatment with dexamethasone ointment. The decision to operate was taken. The surgery protocol: Aseptic cleaning of surgical site with iodine povidone, installation of a sterile field, instill of anesthetic drops, local anesthesia (injection) with 3 ml of lidocaine epinephrine 2%, installation of a Chalazion plate, intralesional vertical incision (facing the tarsal conjunctiva) of 4 mm, curettage of intracystic secretions, the Chalazion plate is removed, the bleeding is minimal, compressive dressing with dexamethasone + framycetin the ointment.

The duration of surgery was 20 min.

One day after surgery, the control already noted: Purplish aspect and edema of eyelid skin, eyelid hypokinesia, and hypoesthesia of eyelid skin.

At 2 days postoperative period, the skin was black with purulent discharge from the incision site.

The pyoculture had highlighted a P. aeruginosa sensitive to quinolones. The patient was hospitalized; ofloxacin intravenous associated with local care (ciprofloxacin eye drops 10 times a day) was established. The HIV serology was negative, and blood glucose was normal.

At 5 days postoperative, the situation was complicated [Figure 1]: No light perception on left eye, dark aspect of eyelid skin, dividing line (healthy skin/diseased skin) along the superior orbital arcade, complete anesthesia of eyelid skin, akinesia of the eyelid, and endophthalmitis (total hypopion).

The lack of technical means did not allow us to continue over the care of this patient who needed major surgery (complete excision with skin grafting, vitrectomy with culture and/or enucleation with fitting prosthesis). Medical evacuation abroad was decided. The examination of the right eye was normal (visual acuity 10/10: Snellen scale).
Figure 1: Gangrene of the eyelid after Chalazion surgery

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  Discussion Top


Chalazion removal surgery is performed under local or general anesthesia. Commonly, general anesthesia is administered in children to make sure they stay still and no injury to the eye occurs. The discomfort of the injection is minimized with the help of an anesthetic cream, which is applied locally. [5] The Chalazion may be removed in two ways, depending on the size of the cyst. Relatively small chalazia are removed through a small cut at the back of the eyelid. [6] The surgeon lifts the eyelid so he or she can access the back of its surface and makes an incision of approximately 3 mm just on top of the Chalazion. The lump is then removed, and pressure is applied for a few minutes to stop any oozing of blood that may occur because of the operation. [5],[6] Surgery of small chalazia does not require stitches, as the cut is at the back of the eyelid, and, therefore, the cut cannot be seen, and the cosmetic result is excellent. Larger chalazia are removed through an incision in front of the eyelid. Larger chalazia usually push on the skin of the eyelid, and this is the main reason why doctors prefer removing them this way. The lump is removed, and then the pressure is applied on the incision to prevent oozing. This type of surgery is closed with very fine stitches. They are hardly visible and are usually removed within a week after the surgery has been performed. Although chalazia are rarely dangerous, it is common to send the Chalazion or part of it to a laboratory to screen for cancer. [1],[6] In rare cases, patients are kept overnight in the hospital after Chalazion surgery. This includes cases in which complications occurred, and the patient needs to be closely monitored. In most cases, however, patients are able to go home after the operation has ended.

The arterial supply of the eyelid has a double origin, a network from the external carotid artery, the other being obtained from the ophthalmic artery. The outcome of the external carotid vasculature is composed by the facial artery and the superficial temporal artery which is divided into three branches: The transverse artery, the zygomatico-malar artery, and the artery under orbital. The ophthalmic artery has two anastomoses branches: Internal frontal artery, the dorsal artery of the nose anastomoses with the angular artery is a terminal branch of the facial artery, and three terminal branches: External frontal artery, the lacrimal artery, the internal eyelid arteries lower, and upper born directly from the ophthalmic artery. [2] Venous blood supply is ensured by a double network. A superficial pretarsal network located between the skin and the orbicularis. For the upper eyelid, it is formed by the angular veins, superficial temporal and superior ophthalmic. For the lower eyelid, it is formed by the facial and superficial temporal veins. A deep network which has two arcades. These arcades draining from the upper eyelid veins to the ophthalmic veins and from the lower eyelid veins to the temporomalar vein. [2] Vascular injury during Chalazion surgery cause rarely serious complications. We only found one case of severe orbital bleeding. [7] The rich vascularization of the eyelids is conducive to intense immune action and therefore an important inflammatory reaction. A postoperative inflammation, usually moderate, is commonplace in the immediate postoperative. Exceptionally, it may jeopardize the patient's visual prognosis. A case of orbital apex syndrome has been reported to date. [8] Sliti et al.[3] has described a case of palpebral acute necrosis due to local anesthesia. May this same mechanism explain the onset of gangrene at this patient ? This hypothesis remains possible since the team formed by Ruiter et al. [9] reported a case of finger amputation after an injection of lidocaine epinephrine association. However, we must be careful because a review of the literature (24 articles, more than 15,000 patients) performed by Nielsen LJ et al. [10] Reports that the local anesthetic + vasoconstrictor combination is safe even in the case of organs with arterial supply end-to-end type. P. aeruginosa is a very virulent germ. This enterobacterium not part of the ecology of bacteria normally present in the conjunctiva. His highlighted in pus from the surgical incision is probably witnessed a nosocomial infection. The combination of several factors may explain the occurrence of rare but serious complication during a yet simple surgery.

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Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Khurana AK, Ahluwalia BK, Rajan C. Chalazion therapy. Intralesional steroids versus incision and curettage. Acta Ophthalmol (Copenh) 1988;66:352-4.  Back to cited text no. 1
    
2.
Werner Kahle. Pocket atlas of anatomy: Nervous system and sense organs. Paris: Flammarion; 2002. p. 338-52.  Back to cited text no. 2
    
3.
Sliti N, Zaraa I, Daoud L, Trojett S, Letaief I, Mokni M, et al. Acute bilateral palpebral necrosis: A rare complication of local anaesthesia. Ann Dermatol Venereol 2010;137:84-5.  Back to cited text no. 3
    
4.
Epstein GA, Putterman AM. Combined excision and drainage with intralesional corticosteroid injection in the treatment of chronic chalazia. Arch Ophthalmol 1988;106:514-6.  Back to cited text no. 4
    
5.
Mustafa TA, Oriafage IH. Three methods of treatment of chalazia in children. Saudi Med J 2001;22:968-72.  Back to cited text no. 5
    
6.
Ben Simon GJ, Rosen N, Rosner M, Spierer A. Intralesional triamcinolone acetonide injection versus incision and curettage for primary chalazia: A prospective, randomized study. Am J Ophthalmol 2011;151: 714-8.e1.  Back to cited text no. 6
    
7.
Procope JA, Kidwell ED Jr. Delayed postoperative hemorrhage complicating chalazion surgery. J Natl Med Assoc 1994;86:865-6.  Back to cited text no. 7
    
8.
Milia M, Lefatzis N, Papakosta V, Theodossiadis P, Papathanassiou M. Unusual case of orbital apex syndrome after chalazion excision. Clin Exp Optom 2013;96:346-8.  Back to cited text no. 8
    
9.
Ruiter T, Harter T, Miladore N, Neafus A, Kasdan M. Finger amputation after injection with lidocaine and epinephrine. Eplasty 2014;14:ic43.  Back to cited text no. 9
    
10.
Nielsen LJ, Lumholt P, Hölmich LR. Local anaesthesia with vasoconstrictor is safe to use in areas with end-arteries in fingers, toes, noses and ears. Ugeskr Laeger 2014;176:V04140238.  Back to cited text no. 10
    


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