eMedicine Specialties > Emergency Medicine > Ophthalmology

Chalazion

Jane Lee Fansler, MD, Resident Physician, Stanford University/Kaiser Permanente Emergency Medicine Residency Program
Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center; Sally Santen, MD, Program Director, Assistant Professor, Department of Emergency Medicine, Vanderbilt University

Updated: Apr 22, 2009

Introduction

Background

Focal swelling of the eyelid is a common complaint that is seen in the primary care or urgent care setting. Often, the swelling can be identified as either a hordeolum (stye) or a chalazion, although several other benign and malignant processes can be mistaken for these two.¹

Chalazion with the lid inverted. Photo by Larry Stack, MD.

Chalazion. Photo by Larry Stack, MD.

It is difficult to state definitively the origin of the word chalazion (pleural: chalazia). Reported origins include Greek words meaning "small lump," "hailstone," or "pimple."

For related information, see Medscape's Ophthalmology Resource Center.

Pathophysiology

A chalazion forms when the meibomian gland becomes blocked and sebaceous secretions accumulate. Reaction to the material results in granulation tissue and chronic inflammation.²

The large meibomian glands are embedded in the tarsal plate of the eyelid; therefore, edema usually is contained on the conjunctival portion of the lid. Occasionally, the chalazion enlarges and breaks through the tarsal plate to the external portion of the eyelid. Blockage of the Zeis glands may cause chalazia to occur along the lid margin.

Chalazia are different from hordeolums in that they form as a result of gland obstruction and sterile inflammation as opposed to a purulent infection of the cilium. Chalazia tend to be larger, less painful, and occur less acutely than hordeolums.

Following the acute inflammation of a hordeolum, a chalazion may occur, in which case, the lesion becomes less painful and eventually painless.

Frequency

United States

Exact incidence or prevalence of chalazia in the United States is not known; however, chalazia are common. Acne rosacea, seborrheic dermatitis, and chronic blepharitis are some predisposing skin and eyelid conditions. Chalazia are more commonly found on the upper eyelid.

International

No known difference exists in international prevalence.

Mortality/Morbidity

• Persistent drainage and swelling can cause irritation to the eye.
• Disease 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 those with atopy.
• Large, centrally located chalazion can cause visual disturbances by pressing on the cornea causing mechanical with-the-rule astigmatism. Acquired hyperopia and decreased vision have been caused by a chalazion of the upper eyelid.³
• Most morbidity is secondary to infection caused by improper drainage. An ophthalmologist or one familiar with eyelid anatomy and necessary surgical techniques would best perform proper surgical management.

Race

No racial predilection is thought to exist.

Sex

Males and females seem to be equally affected.

Age

Chalazia are more common in adults than in children. This is thought to be related to hormonal changes in sebum. The risk of developing chalazia increases in those aged 30-50 years.

• Recurrent chalazion, particularly in the elderly patient, should prompt the practitioner to consider conditions masquerading as a chalazion such as sebaceous carcinoma, squamous cell carcinoma, microcystic adnexal carcinoma, or tuberculosis.
• Children or young adults with recurrent chalazion should prompt the practitioner to examine the patient for viral conjunctivitis and hyperimmunoglobulinemia E (hyper-IgE) syndrome (Job syndrome).

Clinical

History

A chalazion is usually a painless swelling on the eyelid that has been present for weeks to months. Patients may seek medical attention when a chalazion causes impaired vision, double vision, discomfort, or pain or becomes inflamed and painful, or infected.

• The chief complaint must be examined in a thorough manner including questions concerning location, onset, duration, intensity, exacerbating and mitigating factors, previous intervention, and evaluation. If the chalazion is recurrent, inquire how often this has occurred before and if it is in the same location.
• Changes in visual acuity must be clearly documented.
• As the world becomes flatter, and intercontinental travel becomes easier, querying the patient about a travel history, particularly to locations known to be sources of leishmaniasis, is important.⁴
• Document recent viral infections.
• Document immune competency status. Ask if the patient has frequent skin infections.
• Ask about exposure or history of tuberculosis (TB).⁵
• Ask about personal history of cancer.⁶
• Symptoms such as eye pain, acute visual changes, fevers, limitation of extraocular movement, and diffuse eyelid swelling point to a diagnosis other than a chalazion.

Physical

Completely examine the eye and conjunctival surface.

• A chalazion is a palpable nodule on the eyelid.
• Chalazia usually are nontender, nonerythematous, and nonfluctuant. Large chalazia may be tender secondary to size effects.
• Invert the eyelid to visualize the palpebral conjunctiva and identify internal chalazia.
• Chalazia may grow to 7-8 mm in diameter.
• Injection of the conjunctiva is a common secondary finding.
• Examine preauricular nodes to help determine infection.
• No intraocular pathology should be found.
• Presence of fever or distant nodes is not consistent with a chalazion.
• Also note other skin findings including acne, seborrhea, rosacea, and atopy.

Causes

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

• Poor lid hygiene
• Seborrhea
• Acne rosacea
• Chronic blepharitis
• High blood lipid concentrations (possible risk from increased blockage of sebaceous glands)
• Leishmaniasis
• TB
• Immunodeficiency
• Viral infection
• Carcinoma

Differential Diagnoses

Other Problems to Be Considered

Blepharitis
Hyperimmunoglobulinemia E (hyper-IgE) syndrome
Meibomianitis
Meibomian cell carcinoma
Microcystic adnexal carcinoma
Plexiform neurofibroma
Sebaceous carcinoma
Squamous cell carcinoma
Staphylococcus aureus infection
Virus-induced infection

Workup

Laboratory Studies

• The diagnosis of chalazion is usually a clinical one and often does not require further workup. The provider should be certain the eyelid lesion is a sterile inflammation that will resolve with limited intervention.
• The provider must ensure that the patient has an adequate understanding of the typical progression of an uncomplicated chalazion: resolution within a few months. Recurrent symptoms, refractive errors, or persistent lesions should prompt the provider to further investigate the lesion.
• Fine-needle aspiration cytology of chalazia with atypical clinical presentation provides a means of documenting the diagnosis and excluding malignancy but should be deferred to an eye specialist.
• Viral and bacterial cultures can provide results to include or exclude an infectious etiology but tend to be low yield.
• Visual acuity testing
• Visual field testing

Treatment

Emergency Department Care

Conservative management of chalazia includes lid hygiene and warm compresses.⁷ More than 50% of chalazia resolve with conservative treatment. 

• For lid hygiene, patients can use drops of baby shampoo lathered on to and washed off of the affected eyelid.
• Warm compresses should be applied for 15 minutes (4 times per day on an outpatient basis). This encourages resolution of the ductal blockage and aids in sebum drainage. 
• Shampoo to treat seborrhea can be used over the eyebrows to minimize possible ductal blockage from skin particles.
• Topical or systemic antibiotics usually are not necessary because chalazia are secondary to sterile inflammation. Oral tetracyclines may aid in decreasing inflammation and minimizing secondary infection in the acute setting and may also prevent recurrence in the chronic setting. If patients are allergic to tetrcyclines, metronidazole may be used.

Steroid injections and surgical drainage should be deferred to an ophthalmologist or plastic surgeon; these procedures are not generally performed in the ED.⁸ Injection and removal of chalazia may create cosmetic morbidity.⁹

• If no evidence of infection is present, the chalazion can be injected with a steroid (eg, triamcinolone, methylprednisolone) as they can inflammation and frequently cause regression of the chalazion within a few weeks. 0.2-2 mL of 5 mg/mL triamcinolone can be injected directly into chalazion's center. A second injection may be necessary for larger chalazia. Complications of steroid injections include hypopigmentation, atrophy of the area, corneal perforation and traumatic cataract, and potential exacerbation of bacterial or viral infection.
• Excision of chalazion generally is not performed in the ED but involves making a vertical incision in the palpebral conjunctival surface. For small chalazia, curettage of the inflammatory granuloma in the lid is performed. For larger chalazia, dissection of the granuloma may be needed for complete removal. The meibomian gland may also be cauterized or removed. For chalazia extending to the skin, a horizontal incision of the skin surface is used rather than through the conjunctiva to completely remove the inflammation. Involvement of the lid margins raises additional concern of disfigurement.

Consultations

• Refer patients for follow-up care with an ophthalmologist after 2 weeks if conservative management does not completely resolve the chalazion. Refer earlier for recurrent chalazia that have not been further evaluated.
• Consider also referring some patients to dermatologists, as skin disorders predispose to chalazia.

Medication

Since chalazia are sterile inflammations, topical antibiotics usually do not assist in treatment. Chronic oral tetracycline, doxycycline, or metronidazole (Flagyl) may be useful in the setting of chronic, recurrent chalazia. These medications should be prescribed only after evaluation by an ophthalmologist.

Anti-inflammatory Agent

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

Triamcinolone (Amcort)

For inflammatory dermatosis responsive to steroids; decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.

Dosing

Adult

0.1-0.2 mL of 40 mg/mL injected directly into chalazion's center; second injection may be necessary after a few weeks for larger chalazia

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity; fungal, viral, and bacterial skin infections

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

A percentage of topical drug might be absorbed systemically; if application repeated, may experience some systemic effects of corticosteroids; certain skin types may develop loss of eyelid pigmentation after injection; may also experience atrophy of subcutaneous tissues, and risk of developing glaucoma

Follow-up

Further Outpatient Care

• Advise patients to obtain follow-up care with an ophthalmologist if the chalazion does not resolve, has a recurrent episode, or additional symptoms develop.

Deterrence/Prevention

• Classic or typical chalazia do occur with more frequency in patients with immune disorders or acne rosacea and in individuals who have high UV exposure. Medical management of these medical conditions and limiting UV exposure by using sunglasses and hats can theoretically reduce chalazion formation.
• Daily eyelid hygiene can help prevent ductal blockages.
• Using antidandruff shampoo on the eyebrows can lessen the occurrence of skin particles causing blockages, especially in those prone to seborrhea.

Complications

• Potential complications of chalazia are cosmetic deformity and infection, including development of hordeolum or preseptal cellulitis.
• Complications of improper drainage are disruption of lash growth, lid deformity, and lid fistula.
• Visual disturbances can occur with large chalazia.
• Recurrences of chalazia are not uncommon. Potential malignant causes of ductal blockage should especially be addressed in these cases.

Prognosis

• Most chalazia resolve on their own. Conservative management aids in the resolution.
• Recurrences are not uncommon, especially in those with predisposing skin conditions.
• Some specialists recommend biopsy and drainage of all chalazion, primary or recurrent. Specimens should be submitted for histopathologic examination.

Patient Education

• Instruct patients regarding proper use of warm compresses.
• Avoid draining or popping the chalazion.
• For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education articles Chalazion (Lump in Eyelid) and Sty.

Miscellaneous

Medicolegal Pitfalls

• A chalazion is not an emergency medical condition; however, the emergency physician should refer the patient to an ophthalmologist for definitive examination and treatment.
• Applying a warm compress to the chalazion may be satisfactory for the emergency department treatment.
• Recurrent chalazion, missed diagnosis of conditions that masquerade as chalazion, inadvertent corneal perforation, and exacerbation of viral or bacterial infection are risks when the emergency physician assumes primary care responsibility for the chalazion.

Multimedia

Media file 1: Chalazion. Photo by Larry Stack, MD.

Media file 2: Chalazion with the lid inverted. Photo by Larry Stack, MD.

References

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2. Litoff D, Balin MW. Ocular infections and inflammation. In: Catalano RA, ed. Ocular Emergencies. WB Saunders; 1992:468-471.

3. Santa Cruz CS, Culotta T, Cohen EJ, et al. Chalazion-induced hyperopia as a cause of decreased vision. Ophthalmic Surg Lasers. Aug 1997;28(8):683-4. [Medline].

4. Berman JD. Human leishmaniasis: clinical, diagnostic, and chemotherapeutic developments in the last 10 years. Clin Infect Dis. Apr 1997;24(4):684-703. [Medline].

5. Aoki M, Kawana S. Bilateral chalazia of the lower eyelids associated with pulmonary tuberculosis. Acta Derm Venereol. 2002;82(5):386-7. [Medline].

6. Khan JA, Doane JF, Grove AS Jr. Sebaceous and meibomian carcinomas of the eyelid. Recognition, diagnosis, and management. Ophthal Plast Reconstr Surg. 1991;7(1):61-6. [Medline].

7. Goawalla A, Lee V. A prospective randomized treatment study comparing three treatment options for chalazia: triamcinolone acetonide injections, incision and curettage and treatment with hot compresses. Clin Experiment Ophthalmol. Nov 2007;35(8):706-12. [Medline].

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

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

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Keywords

chalazion, chalazia, nodule on eyelid, meibomian glands, deep chalazion, Zeis sebaceous glands, superficial chalazion, painless granuloma on eyelid, painless swelling on eyelid, seborrhea, acne rosacea, chronic blepharitis, high blood lipid concentrations, meibomian cyst, meibomian gland lipogranuloma, tarsal cyst

Contributor Information and Disclosures

Author

Jane Lee Fansler, MD, Resident Physician, Stanford University/Kaiser Permanente Emergency Medicine Residency Program
Jane Lee Fansler, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Emergency Medicine Residents Association, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
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.

Medical Editor

David FM Brown, MD, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Harvard Medical School; Associate-Chief, Attending Physician, 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: Schering  Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Douglas Lavenburg, MD, Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems
Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
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.

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