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Chalazion

  • Author: Jean Deschênes, MD, FRCSC; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Dec 02, 2015
 

Background

Focal swelling of the eyelid is a common complaint in both primary care and urgent care settings. Often, such swelling is identified as either a chalazion, appearing as a characteristically hard and painless lid nodule, or a hordeolum (stye), although several other benign and malignant processes can be mistaken for these two.[1]

Chalazia (plural of chalazion), which are the most common inflammatory lesions of the eyelid, are slowly enlarging eyelid nodules, formed by inflammation and obstruction of sebaceous glands. Chalazia can be categorized as either superficial or deep, depending on the glands that are blocked. Inflammation of a meibomian gland leads to a deep chalazion, whereas inflammation of a Zeis gland leads to a superficial chalazion. Chalazia can recur, and those that do should be evaluated for malignancy; following drainage, the content should be sent for pathologic examination.

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Pathophysiology

Chalazia form when lipid breakdown products, possibly from bacterial enzymes or retained sebaceous secretions, leak into surrounding tissue and incite a granulomatous inflammatory response.[2]

Since meibomian glands are embedded in the tarsal plate of the eyelids, edema due to blockage of these glands is usually contained on the conjunctival portion of the lid; on occasion, a chalazion may enlarge and break through the tarsal plate to the external portion of the lid. Chalazia due to blockage of Zeis glands are usually located along the lid margin.

Chalazia differ from hordeola in that they form as a result of gland obstruction and sterile inflammation rather than infection. Whereas a chalazion is characterized by a mass of granulation tissue and chronic inflammation (with lymphocytes and lipid-laden macrophages), an internal or external hordeolum is primarily an acute pyogenic inflammation with polymorphonuclear leukocytes (PMNs) and necrosis with pustule formation.

In general, chalazia tend to be larger, less painful and have a less acute presentation than hordeola.[3] However, one condition can result in the other. The acute inflammation of a hordeolum may eventually lead to a chronic painless chalazion, while a chalazion can also become acutely infected.

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Etiology

Chalazia occur after gland blockage, which can be associated with the following:

  • Poor lid hygiene (the precise causal role has not yet been established)
  • Rosacea
  • High blood lipid concentrations (possible risk from increased blockage of sebaceous glands)
  • Leishmaniasis
  • Tuberculosis
  • Immunodeficiency
  • Viral infection
  • Carcinoma
  • Stress (causality has not been proven, and the mechanism by which it might act is unknown)

As noted (see Pathophysiology), a chalazion may arise spontaneously subsequently to the development of an internal hordeolum.

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Epidemiology

United States and international statistics

Chalazia are common, but their exact incidence and prevalence in the United States are not known. Data about the worldwide prevalence or incidence of chalazia are also unavailable.

Age-related demographics

Although chalazia occur in all age groups, they are more common in adults (especially those aged 30-50 years) than in children, presumably because androgenic hormones increase sebum viscosity. Hormonal influences on sebaceous secretion and viscosity may explain clustering at the time of puberty and during pregnancy; however, the large number of patients without evidence of hormonal alteration suggests that other mechanisms also apply. Chalazia are uncommon at the extremes of age, but pediatric cases may be encountered.

Recurrent chalazion, particularly in elderly patients, should prompt the practitioner to consider conditions that may masquerade as a chalazion (eg, sebaceous carcinoma, squamous cell carcinoma, microcystic adnexal carcinoma, tuberculosis). Recurrent chalazion in a child or young adult should prompt an evaluation for viral conjunctivitis and hyperimmunoglobulinemia E (hyper-IgE) syndrome (Job syndrome).

Sex- and race-related demographics

Chalazia appear to affect males and females equally, but as noted, precise information about prevalence and incidence is not available. Contrary to popular opinion, research has not shown that the use of eyelid cosmetic products either causes or aggravates the condition.

No information about prevalence or incidence with respect to race is available.

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Prognosis

Conservative management facilitates resolution of chalazia, and patients receiving therapy usually have an excellent outcome. Untreated chalazia occasionally drain spontaneously but are more likely to persist with intermittent acute inflammation compared to treated chalazia. When untreated, new lesions often develop, and inadequate drainage may result in local recurrences, especially if a predisposing skin condition is present.

Morbidity associated with chalazia may include the following:

  • Acute inflammatory exacerbation can lead to an anterior (through the skin) or a posterior (through the conjunctiva) rupture, forming a granuloma pyogenicum
  • Persistent drainage and swelling can cause irritation to the eye
  • Progression of a chalazion can lead to a disfiguration of the eyelids; continued inflammation could also lead to a pyogenic granuloma
  • Chalazia can predispose to preseptal cellulitis, especially in individuals with atopy
  • Large, centrally located chalazia can cause visual disturbances by pressing on the cornea, causing mechanical with-the-rule astigmatism; acquired hyperopia and decreased vision have also been reported with chalazia of the upper eyelid [4]
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Patient Education

The clinician should ensure that patients have an adequate understanding of the typical progression of an uncomplicated chalazion, that is, resolution within a few weeks to a few months. Patients should receive instructions regarding the importance of adequate lid hygiene and general health measures (eg, rest, stress management, proper diet) to maintain good skin function. The clinician should explain that although the lesions are benign, meticulous lid hygiene and dedication may be required as curative and preventive measures.

The following measures (in decreasing order of importance) should be recommended:

  • Gentle but firm and vigorous massages to promote drainage of the obstructed gland (with care taken not to rupture the chalazion)
  • Application of warm compresses to help melt the viscous lipids
  • Use of water and baby shampoo, which does not sting if it gets into the eye, to remove the secretions collecting on the margins of the lids

More complex procedures may be preferred. An example is the use of diluted baby shampoo on a cotton wool applicator to rub along the mucocutaneous junction and gray line of the lid. However, methods such as this one do not promote adequate drainage of the glandular secretions; they are also cumbersome and difficult, and additional paraphernalia are required.

For patient education resources, see the Eye and Vision Center, as well as Chalazion (Lump in Eyelid) and Sty.

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Contributor Information and Disclosures
Author

Jean Deschênes, MD, FRCSC Professor, Research Associate, Director, Uveitis Program, Department of Ophthalmology, McGill University Faculty of Medicine; Senior Ophthalmologist, Clinical Director, Department of Ophthalmology, Royal Victoria Hospital, Canada

Jean Deschênes, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, Canadian Medical Association, Canadian Ophthalmological Society, Quebec Medical Association, International Ocular Inflammation Society

Disclosure: Nothing to disclose.

Coauthor(s)

Jane Lee Fansler, MD, FACEP Assistant System Medical Officer, Clayton Emergency Group

Jane Lee Fansler, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Phi Beta Kappa

Disclosure: Nothing to disclose.

Alexandre Plouznikoff, MD, PhD MASc, BEng, Resident Physician, Department of Ophthalmology, McGill University Faculty of Medicine, Canada

Alexandre Plouznikoff, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Acknowledgements

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences,and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

David FM Brown, MD Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: lippincott Royalty textbook royalty; wiley Royalty textbook royalty

Jorge G Camara, MD Professor of Ophthalmology, Department of Surgery and Director of Fellowship Training Program in Ophthalmic Plastic and Reconstructive Surgery for Countries Served by the Aloha Medical Mission, University of Hawaii John A Burns School of Medicine

Jorge G Camara, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and American Society of Ophthalmic Plastic and Reconstructive Surgery

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Sally Santen, MD Program Director, Assistant Professor, Department of Emergency Medicine, Vanderbilt University

Sally Santen, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
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  9. Sharma R, Brunette DD. Ophthalmology. In: Marx, ed. Rosen’s Emergency Medicine. Vol 2. 7th ed. 2009:Chap 69.

  10. Ho SY, Lai JS. Subcutaneous steroid injection as treatment for chalazion: prospective case series. Hong Kong Med J. 2002 Feb. 8(1):18-20. [Medline].

  11. Hosal BM, Zilelioglu G. Ocular complication of intralesional corticosteroid injection of a chalazion. Eur J Ophthalmol. 2003 Nov-Dec. 13(9-10):798-9. [Medline].

  12. Gilchrist H, Lee G. Management of chalazia in general practice. Aust Fam Physician. 2009 May. 38(5):311-4. [Medline].

  13. Ben Simon GJ, Huang L, Nakra T, Schwarcz RM, McCann JD, Goldberg RA. Intralesional triamcinolone acetonide injection for primary and recurrent chalazia: is it really effective?. Ophthalmology. 2005 May. 112(5):913-7. [Medline].

  14. 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 Apr. 151(4):714-718.e1. [Medline].

  15. Wong MY, Yau GS, Lee JW, Yuen CY. Intralesional triamcinolone acetonide injection for the treatment of primary chalazions. Int Ophthalmol. 2014 Oct. 34(5):1049-53. [Medline].

 
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Chalazion. Image courtesy of Larry Stack, MD
Chalazion with eyelid everted. Image courtesy of Larry Stack, MD.
 
 
 
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