History
A chalazion usually presents as a painless swelling on the eyelid that has been present for weeks to months. [1] Patients may seek medical attention only when the condition worsens, as when a chalazion causes impaired vision or discomfort or becomes inflamed, painful, or infected. Frequently, there is a long history of previous similar occurrences because chalazia tend to recur in predisposed individuals.
The chief complaint must be examined thoroughly, including questions regarding the location of the lesion, its onset, duration, intensity, and exacerbating and mitigating factors, as well as previous interventions and evaluations. If the chalazion is recurrent, the patient should be asked how often it has occurred before and if the new lesion is in the same location as a previous one.
As intercontinental travel becomes easier, it is increasingly important to inquire into the patient’s history of travel, particularly to regions known to be endemic for tuberculosis and leishmaniasis. [8]
The following should be documented [1] :
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Any changes in visual acuity
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Any recent viral infections
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Any recent antibiotic use
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Immunocompetence
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Any history of frequent skin infections
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History of lid trauma
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History of previous ocular surgery
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Chemical or toxin exposure
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Significant allergies
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Any exposure to or history of tuberculosis [9]
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Any personal history of cancer [10]
Symptoms such as eye pain, acute visual changes, recurrence in the same exact location, fever, limitation of extraocular movement, and diffuse eyelid or facial swelling point to a diagnosis other than a chalazion.
Physical Examination
A complete examination of the eye and of the conjunctival surface should be carried out. [1] A chalazion takes the form of a palpable nodule on the eyelid, sometimes as large as 7-8 mm in diameter. Usually, it is firm, nonerythematous, nonfluctuant, and nontender, although a large or acute chalazion may be tender as a consequence of size effects. Chalazia are more common on the upper lid (see the image below) than on the lower lid because of the increased number and length of meibomian glands present in the upper lid.
Physical features help distinguish a chalazion from a hordeolum. Patients with the former generally have a single firm nontender nodule, or in rare cases, multiple nodules, located deep within the lid or the tarsal plate, whereas patients with the latter have a more superficial and painful lesion that is typically centered on an eyelash.
The eyelid should be everted to allow visualization of the palpebral conjunctiva and to identify an internal chalazion (see the image below).
Eversion of the lid may reveal a dilated meibomian gland and chronic inspissation of adjoining glands. A gentle compression of these glands frequently produces copious toothpaste-like secretions instead of the normal small amount of clear oily secretions. The eye can be examined with a slit lamp to rule out madarosis (lash loss), poliosis (lash whitening), and ulceration, which should raise suspicion for other etiologies.
The following should be kept in mind during the physical examination:
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Injection of the palpebral conjunctiva is a common secondary finding
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Preauricular nodes should be examined to help determine whether an infection is present
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No intraocular pathology should be found
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The presence of fever or distant nodes is not consistent with a chalazion
Other skin findings, such as acne, seborrhea, rosacea, or atopy, should be noted. Rosacea is a finding frequently associated with a chalazion. When present, rosacea demonstrates specific characteristics, such as facial erythema; telangiectatic and spider nevi on the malar, nasal, and lid skin and along the lid margins; and rhinophyma.
Complications
Potential complications of chalazia include lash loss, lid notching, and other cosmetic deformity and adjunctive infection, including the development of hordeolum or preseptal cellulitis.
Improperly drained marginal chalazia can result in notching, trichiasis, and loss of lashes. Partially drained chalazia can result in large masses of granulation tissue prolapsing through the conjunctiva or skin.
Visual disturbances can occur with large chalazia, and astigmatism may arise when the lid mass distorts the corneal contour.
Recurrences of chalazia are not uncommon. However, the physician should entertain the possibility of malignancy in such cases and should biopsy a lesion that recurs or appears atypical. The pathologist should be alerted to the suspicion of sebaceous cell carcinoma and frozen sections and lipid stains should be requested.
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Chalazion. Image courtesy of Larry Stack, MD
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Chalazion with eyelid everted. Image courtesy of Larry Stack, MD.
