eMedicine Specialties > Ophthalmology > Lid

Chalazion: Treatment & Medication

Author: Izak F Wessels, MB, BCh, MMed, FRCSE, FRCO, BSc, FACS, Associate Professor, Department of Ophthalmology, Chattanooga Unit, University of Tennessee College of Medicine; Private Practice in Comprehensive and Surgical Ophthalmology, Allied Eye Associates
Contributor Information and Disclosures

Updated: Aug 3, 2007

Treatment

Medical Care

Small, inconspicuous, asymptomatic chalazia may be ignored. Conservative treatment with lid massage, moist heat, and topical mild steroid drops usually suffices.  Acute therapy with oral tetracycline (eg, doxycycline 100 mg or minocycline 50 mg qd for 10 d) minimizes the infectious component and decreases the inflammation, reputedly by inhibiting polymorph degranulation.  Chronic therapy with low-dose tetracycline (eg, doxycycline 100 mg PO qwk for 6 mo) frequently prevents recurrence.  If tetracycline cannot be used, then metronidazole has been used in a similar fashion.  In most cases, surgery should be performed only after a few weeks of medical therapy.

• For local nonsurgical care early in the condition, blocked glandular orifices may be opened by means of vigorous massage between 2 cotton wool buds at the slit lamp. Local anesthesia may be beneficial to facilitate a thorough massage.
• A wet facecloth, as hot as can be tolerated, can be applied twice daily to promote drainage by melting the lipid secretions.
• A self-administered technique called the "4 fingers times 10 massage" can be beneficial.
• This technique is performed as follows: At the conclusion of a bath or shower, the patient warms his or her hands under hot water. Using 1 drop of baby shampoo (which does not sting the eyes), the patient works up a lather, places the index finger over the closed lids at the lid margin, and vigorously massages the lid back and forth 10 times. The patient then repeats the procedure with the middle, ring, and little fingers.
• Most marginal chalazia are connected to another chalazion located deeper in the substance of the lid.
• The contents of a purely marginal chalazion may be expressed by rolling 2 cotton-tipped applicators toward the lid margin from both sides of the lid.
• If the contents cannot be expressed, incise the distal chalazion, and curette the contents.
• The management of infected chalazia (ie, internal hordeolum) includes heat and topical and/or systemic antibiotics.
• In select cases, incision and drainage may be beneficial.
• Evacuate only the pus; overly aggressive curettage can disseminate the infection by breaking down tissue barriers.
• Topical steroids are necessary to prevent the chronic inflammatory response, as well as the acute noninfectious reaction produced by irritants (eg, free fatty acids liberated by bacterial enzymes) from causing excessive scarring.
• Once the acute inflammation has subsided, revision and definitive curettage or excision of the granulomatous mass may be required.

Surgical Care

Drainage by means of a transconjunctival incision and curettage is optimal. Establish anesthesia by means of a local infiltration, possibly augmented with topical anesthetic cream (eutectic mixture of local anesthetics [EMLAs]) to reduce the pain of the injection in young patients.  With recurrent chalazia, it is imperative that a biopsy be performed, with histological evaluation using fat stains (specifically request this on the specimen) to rule out sebaceous cell carcinoma.

• Apply a chalazion clamp to evert the lid and to control bleeding.
  • Vertically incise the lesion with a sharp blade, going no closer than 2-3 mm to the lid margin. Avoid perforating the skin.
  • Curette the contents, including any cyst lining.
  • A few minutes of pressure are usually sufficient to achieve hemostasis.
  • A light pressure bandage should be applied for a few hours to absorb any further oozing.
• If previous external drainage (or granuloma extension) was performed, an external approach may be recommended.
  • Make the incision horizontally, at least 3 mm from the lid margin in an existing crease.
  • Do not sacrifice normal tissue.
  • After hemostasis, the wound may be closed with appropriate sutures (eg, 7-0 silk).
  • Involvement of both skin and conjunctiva may require offsetting the incisions to avoid fistula formation.
  • Cauterization with phenol or trichloroacetic acid after incision and drainage may prevent the recurrence of small chalazia.
• Large or chronically neglected and excessively fibrotic chalazia may require more extensive surgical excision, including removal of parts of the tarsal plate.
  • Leaving a 3-mm bridge of normal tarsus near the lid margin prevents notching.
  • Multiple chalazia may be excised carefully, without fear of major lid deformity; the fibrous tarsal plate heals without leaving gaps.
  • Even complete tarsal plate removal has been reported not to cause a lid deformity.
• A local intralesional corticosteroid injection (0.5-2 mL triamcinolone acetonide 5 mg/mL) is administered and can be repeated in 2-7 days.
  • Soluble aqueous preparations are preferred to crystalline suspensions to minimize complications of hypopigmentation, atrophy, or a visible depot of medication.
  • A transconjunctival injection route may also provide a further safeguard.
  • Injection or cautious surgical drainage of a chalazion located near the lacrimal drainage system can prevent serious complications involving tear flow.
• Biopsy may be performed by simply excising a section of the remaining edge of the lesion. Do not overlook the specific request to the pathologist to rule out sebaceous cell carcinoma and to especially consider using fat stains (ie, do not have the specimen processed as usual).

Consultations

Referral to a dermatologist may be beneficial to help treat problems with rosacea or sebaceous dysfunction.

Diet

Dietary modification has not been evaluated.

• Similar advice given to manage severe acne may be appropriate in certain individuals; this advice is as follows: avoid or decrease the ingestion of coffee, chocolate, and highly refined foods, as well as fried foods and those containing saturated fats.
• On average, most of the public is not consuming sufficient amounts of vegetables and fruits, fresh or cooked, to meet the minimum recommendations of the American Dietary Association.
• Dietary supplements with omega-3 and omega-6 fatty acids, available in flax seeds or in flax seed oil, may be beneficial. A practical and simple intervention is to use a coffee grinder to grind flax seeds into meal.  One tablespoon per day of fresh meal is an excellent dietary supplement and quite palatable.

Activity

Regular habits of sufficient sleep, moderate sun exposure, exercise, and fresh air may be of benefit to cutaneous health and hygiene of the skin and glands of the eyelids. Stress is often associated with episodes of recurrent chalazia, although a causal role has not been established.

Medication

Medical therapy is only rarely indicated, except in cases of rosacea, for which a 6-month course of low-dose tetracycline may be of benefit. Doxycycline in dosages of as little as 100 mg every week for 6 months may result in permanent biochemical change, with the sebaceous glands producing shorter-chain fatty acids, which are less likely than longer-chain fatty acids to congeal and block the gland orifices.

Although probably innocuous, topical antibiotics do not help this condition, which is not infectious. Systemic tetracycline may be beneficial, but local drops are unlikely to help and are more likely to cause a contact dermatitis-type reaction. Topical steroids can be helpful in minimizing inflammation and in reducing edema, thereby facilitating any drainage that may take place.

Antibiotics

Antibiotics are not indicated as treatment of infection. Significant benefit may be derived from low-dose, long-term therapy with tetracycline.

Tetracycline (Sumycin)

Useful adverse effect is altering bacterial flora in skin and altering lipids to produce shorter-chain fatty acids, lowering melting point of sebaceous secretions, which may prevent blockage of meibomian glands.

Doxycycline (Bio-Tab, Doryx, Vibramycin)

Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Alters lipids to produce shorter-chain fatty acids, lowering melting point of sebaceous secretions, which may prevent blockage of the meibomian glands.

Minocycline (Dynacin, Minocin)

Adverse effect alters lipids to produce shorter-chain fatty acids, lowering melting point of sebaceous secretions, which may prevent blockage of the meibomian glands.

Metronidazole (Flagyl)

Taken orally, may benefit patients unable to take tetracyclines.

Corticosteroids

Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the immune response of the body to diverse stimuli.

Triamcinolone acetonide (Kenalog, Aristocort)

Advantages of Kenalog over other depot corticosteroids (eg, Celestone) are less discomfort and reduced cost. For inflammatory dermatosis responsive to steroids; decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Used to minimize scarring and inflammation.

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