Chalazion 

Updated: Dec 09, 2019
Author: Jean Deschênes, MD, FRCSC; Chief Editor: Andrew A Dahl, MD, FACS 

Overview

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 firm and painless lid nodule, or a hordeolum (stye), which is usually painful and tender, although several other benign and malignant processes can be mistaken for these two.[1]

Chalazia (plural of chalazion), the most common inflammatory lesions of the eyelid, are slowly enlarging eyelid nodules, formed by inflammation and obstruction of sebaceous glands of the eyelids. Chalazia can be categorized as either superficial or deep, depending on the glands that are blocked. Inflammation of a tarsal 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 excision of a recurrence, the content should be sent for pathologic examination.

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] . An alternate name for chalazion is conjunctival granuloma.

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.

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)
  • Trachoma
  • Eyelid trauma
  • Eyelid surgery
  • Bortezomib, a first-generation proteasome inhibitor used to treat hematological malignancies [4]

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

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.

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, including depigmentation, hyperpigmentation, lid-margin notching, tarsal fibrosis with subsequent entropion, and madarosis (lash loss); 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[5]

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 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
  • Lid scrubbing with one of the many commercially available eyelid hygiene solutions, including hypochlorous acid, lavender, or various soaps
  • Use of water-diluted baby shampoo, which does not sting if it gets into the eye, to remove the secretions collecting on the margins of the lids
  • Commercially available heating or cleaning devices
  • Thermal pulsation therapy, an in-office procedure that provides a constant temperature of 42.5°C to the entire eyelid accompanied by cleansing outward compression (Lipiflow, Tear Science, Morrisville, North Carolina)
  • Nutritional supplementation with essential fatty acids
  • Oral antibiotic therapy with doxycycline or minocycline, both tetracycline class agents with lipolytic, anti-inflammatory, and anti-MMP-9 activity, especially in patients with frequent new chalazia or acne rosacea as an underlying predisposing factor

More complex procedures may be preferred. An example is the use of diluted baby shampoo on a cotton 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.

 

Presentation

History

A chalazion usually presents as a painless swelling on the eyelid that has been present for weeks to months. 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.[6]

The following should be documented:

  • Any changes in visual acuity
  • Any recent viral infections
  • Any recent antibiotic use
  • Immunocompetence
  • Any history of frequent skin infections
  • History of lid trauma
  • History of previous ocular surgery
  • Chemical or toxin exposure
  • Significant allergies
  • Any exposure to or history of tuberculosis [7]
  • Any personal history of cancer [8]

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. 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.

Chalazion. Image courtesy of Larry Stack, MD Chalazion. Image courtesy of Larry Stack, MD

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).

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

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:

  • Injection of the palpebral conjunctiva is a common secondary finding

  • Preauricular nodes should be examined to help determine whether an infection is present

  • No intraocular pathology should be found

  • 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.

 

DDx

Diagnostic Considerations

In addition to the conditions listed in the differential diagnosis, other problems to be considered include the following:

  • Hyperimmunoglobulinemia E (hyper-IgE) syndrome (Job syndrome)
  • Meibomianitis
  • Meibomian cell carcinoma
  • Microcystic adnexal carcinoma
  • Plexiform neurofibroma
  • Staphylococcus aureus infection
  • Virus-induced infection
  • Ingrown lash follicles
  • Retained foreign body

Differential Diagnoses

 

Workup

Approach Considerations

The diagnosis of chalazion is usually clinical and often does not require further workup. The healthcare provider should be certain that the eyelid lesion is a sterile inflammation that will resolve with limited intervention. Recurrent symptoms or persistent lesions should prompt further investigation.

Recurrent chalazia, especially if they recur despite previous successful drainage in the same exact location, must be considered potentially malignant and biopsied. Some specialists recommend biopsy and drainage of all chalazia, whether primary or recurrent.

Laboratory Studies

The material obtained from a chalazion shows a mixture of acute and chronic inflammatory cells, as well as large, lipid-filled, foreign body−type giant cells. Lipid analysis may reveal fatty acids with long carbon chains that result in an increased melting point. This finding possibly accounts in part for the blockage of secretions.

Viral and bacterial cultures may help pinpoint an infectious etiology but tend to have a low yield. Although bacterial culture findings are often negative, S aureus, Staphylococcus albus, or another cutaneous commensal organism may be isolated. Propionibacterium acnes may be present in the glandular contents. Appropriate selection of topical or systemic antibiotics is best directed by culture and sensitivity results, particularly in recalcitrant, chronic, or recurrent cases.

Fine-needle aspiration cytology of atypical chalazia can confirm a diagnosis and exclude malignancy. It is best performed by an eye specialist.

Other Studies

Visual acuity testing and visual field testing should also be considered as appropriate. It is essential to evert the superior tarsus whenever tolerable by the patient.

Histologic Findings

Histologic examination reveals a chronic granulomatous reaction with numerous lipid-filled, Touton-type giant cells. Typically, the nuclei of these cells are located around a central foamy cytoplasmic area that contains the ingested lipid material. Other typical mononuclear cells, including lymphocytes or macrophages, may also be found at the periphery of the lesion.

In the event of a secondary bacterial infection, an acute necrotic reaction with PMNs may ensue.

Destruction of the fibrocartilage of the tarsal plate may be evident.

Foreign bodies, such as embedded parts of polymethyl methacrylate [PMMA] contact lenses in the tarsal plate, have also been encountered in cases of chronic chalazia.

Imaging Studies

Infrared photographic imaging of the meibomian glands can demonstrate abnormally dilated glands through the everted lid, as well as inspissated secretions.

Point of service clinical imaging of meibomian gland architecture is readily available from Tear Science (LipiView and LipiScan), as well as Oculus (Keratography 5-M).

 

Treatment

Approach Considerations

Although a chalazion is not an emergency medical condition, an acute and inflamed chalazion may motivate a patient to seek treatment in the emergency department (ED). Conservative management (see Conservative Measures) should be initiated by the emergency or family physician; if the chalazion does not resolve within one month, the patient should be referred to an ophthalmologist for definitive examination and treatment.

Small, inconspicuous, asymptomatic chalazia may be ignored. Otherwise, conservative treatment with lid massage, moist heat, and topical mild steroid drops should suffice.[9] Intralesional steroid injection may also be used for small lesions and lesions that are close to the lacrimal apparatus. Antibiotics are usually unnecessary but should be considered in cases of possible primary or secondary infection. A short course of topical antibiotic ointment can be considered if the lesion is actively draining or associated with blepharoconjunctivitis. In select cases, incision and drainage may be beneficial. The combination of steroid injection and excision yields a 95% resolution rate. Urgent transfer to an orbital or ophthalmic plastic surgeon is mandatory if a sebaceous cell carcinoma is documented by biopsy results or suggested by clinical findings.

Occasionally, patients present with profound concern about the causal factors for lid inflammation, including chalazion. They may have major anxiety because of misinformation that severe Demodex folliculorum infestation may have triggered their lid disease. However, there is no evidence that Demodex causes lid disease; it appears to be a harmless commensal organism, though it has been implicated in canine mange in dogs. Treatment of demodicosis includes nocturnal application of ointment to the eyes, which smothers the parasite.

Conservative Measures

Conservative management of chalazia includes warm compresses and lid hygiene.[10, 11] More than 50% of chalazia resolve with conservative treatment.

Warm compresses with a wet facecloth, as hot as can be tolerated, can be used to melt the lipid secretions, thereby encouraging resolution of the ductal blockage and facilitating the drainage of sebum. Compresses should be applied on the eyelids for 15 minutes 2-4 times per day. A wide variety of commercially available reusable compress devices are readily available to the patient and to the eye care professional.

Baby shampoo or commercial lid wipes can be used over the eyelashes to remove debris blocking the ducts opening. Particularly useful are products containing hypochlorous acid, a naturally occurring bactericidal and anti-inflammatory agent found in leukocyte phagocytic vesicles (Avenona, Novabay; Hypochlor, Ocusoft). Shampoo to treat seborrhea can also be used over the eyebrows to minimize possible ductal blockage from skin particles, particularly in patients with seborrheic dermatitis and anterior blepharitis.

A self-administered technique that can be beneficial is the “4 fingers times 10” massage, which 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 hypochlorous acid scrub or baby shampoo, which does not sting the eyes, the patient works up a lather
  • The patient closes both eyes and covers the lashes and both the upper and lower eyelids with the index finger
  • With the index finger placed over the closed lids at the lid margin, the patient vigorously massages the lid back and forth 10 times
  • The patient then repeats the procedure with the middle, ring, and little fingers
  • Finally, the patient rinses off the remaining shampoo
  • The entire procedure can be performed with a sterile 2-inch by 2-inch gauze pad, a cotton ball, or a similar clean disposable provided in lid scrub kits

In the office, and early in the course of a chalazion, a blocked glandular orifice may be opened, and the content of the chalazion expressed by means of vigorous massage between two cotton wool buds, preferably at the slit lamp; local anesthesia may be beneficial to facilitate a thorough massage. This technique works best for marginal chalazia and for chalazia not connected to another chalazion located deeper in the substance of the lid. If the contents cannot be expressed, the distal or deeper chalazion should be incised and the contents curetted (see Surgical Intervention).

Pharmacologic Therapy

For the most part, topical or systemic antibiotics are not necessary, because chalazia are usually secondary to sterile inflammation. If the lesion is actively draining or associated with blepharoconjunctivitis, a topical antibiotic ointment can be applied for 1-2 weeks (erythromycin or bacitracin BID). If an infectious process is present, acute therapy with azithromycin or a tetracycline, such as doxycycline 100 mg PO BID or minocycline 50 mg PO QD for 10 days, minimizes the infectious component and decreases inflammation. The beneficial non-antimicrobial effects of tetracycline class antibiotics reputedly include inhibiting polymorph degranulation, reducing meibomian secretion viscosity, decreasing collagenase production, and inhibiting matrix metalloprotease 9 (MMP-9) activity. Long-term low-dose tetracycline class therapy frequently prevents recurrence.

Maintenance therapy with doxycycline 20 mg PO QD or 50 mg PO QD is often very effective, particularly in the presence of oculocutaneous acne rosacea. Weekly pulse therapy is also effective, as is maintenance therapy administered one week per month. Some clinicians recommend year-round treatment for severe recurrent cases, often taking a one-month break in June, when phototoxicity is most likely.

When tetracyclines cannot be used because of patient allergy, phototoxicity, or gastrointestinal irritation, metronidazole may be used in a similar fashion. In most cases, surgery should be performed only after attempting a few weeks of medical therapy first.

Topical steroids may be necessary to prevent the chronic inflammatory response, as well as the acute noninfectious reaction produced by irritants such as free fatty acids liberated by bacterial enzymes. Effective medical and surgical therapy can prevent excessive scarring. Once the acute inflammation has subsided, revision and definitive curettage or excision of the granulomatous mass may be required.

If no evidence of infection is present, local intralesional injection of a steroid (triamcinolone or methylprednisolone) can reduce inflammation and may cause regression of the chalazion within a few weeks. This method is especially considered when the chalazion is small or near the lacrimal apparatus. Typically, 0.2-2 mL of 40 mg/mL triamcinolone is injected directly into the chalazion’s center. The latter can be mixed 1:1 with 2% lidocaine with epinephrine to reduce pain. A second injection 2-7 days later may be necessary for larger chalazia.[12]

A study by Ben Simon et al compared triamcinolone acetonide injections with incisions and curettage in 94 patients with chalazion.[13] The study determined that intralesional triamcinolone acetonide injection was as effective as incision and curettage and that it may be considered as an alternative first-line treatment when the diagnosis is straightforward, when biopsy is not required, or when the lesion is located near the lacrimal drainage system, where an incision could cause complications involving tear flow.

Although steroid injections appear to be safe and effective in the treatment of primary chalazia,[14] potential complications include permanent depigmentation (especially in dark-skinned individuals), atrophy of the area, corneal perforation and traumatic cataract, elevated intraocular pressure, a visible depot of medication, and potential exacerbation of bacterial or viral infections. To minimize the risk of such complications, soluble aqueous preparations such as dexamethasone may be preferred to crystalline suspensions. Rarely, injection of large volume of steroid into an eyelid lesion may result in central retinal artery occlusion via retrograde intra-arterial filtration.[15] A transconjunctival injection route may provide a further safeguard. The risks and benefits of steroid use should be discussed with the patient.

Use of steroids and surgical drainage (see below) should be reserved for an ophthalmologist or a plastic surgeon.[16] Injection and removal of chalazia may create cosmetic morbidity.[17]

Surgical Intervention

Proper surgical management is best performed by an ophthalmologist or another practitioner who is thoroughly familiar with eyelid anatomy and necessary surgical techniques. Anesthesia is established by means of a local infiltration, possibly augmented with topical anesthetic cream or solution (eutectic mixture of local anesthetics [EMLAs] or 4% topical lidocaine applied with a pledget or sterile cotton-tipped applicator) to reduce the pain of the injection in younger patients. A mixture of steroid plus lidocaine can also be very effective following topical anesthetic application.

A chalazion clamp is applied to evert the lid and to control bleeding. A transconjunctival vertical incision, to avoid damaging nearby glands, is made in the lesion with a sharp blade, going no closer than 2-3 mm to the lid margin. Care must be taken to keep from perforating the skin and when incising near the lacrimal drainage system to prevent serious complications involving tear egress. For small chalazia, curettage of the inflammatory granuloma in the lid, including any cyst lining, is performed. Curettage should not be overly aggressive, as it can disseminate the inflammation by breaking down tissue barriers. For larger chalazia, dissection of the granuloma may be needed for complete removal. The meibomian gland may be cauterized with a hyfrecator or low-voltage Bovie, cauterized with phenol or trichloroacetic acid, or even removed to prevent recurrences.

After removing the chalazion clamp, a topical antibiotic ointment covering the normal skin flora (bacitracin, bacitracin/polymyxin B [Polysporin], or erythromycin) can be applied to the incision site to prevent infection. A few minutes of pressure usually suffices to establish hemostasis. Finally, after removing the inevitable large tenacious blood clot from the conjunctiva, a light pressure bandage should be applied for a few hours to absorb any further oozing.

If a chalazion threatens to break through the skin or has drained through, an external approach may be recommended. A horizontal incision is made in the skin at least 3 mm from the lid margin in an existing crease, with care taken not to sacrifice normal tissue. Curettage and dissection are then performed as above. After hemostasis is achieved, the wound may be closed with appropriate sutures, such as 6-0 plain catgut or 6-0 silk.

Note that involvement of both skin and conjunctiva may necessitate offsetting the incisions to avoid fistula formation.

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 and potential deformity. Multiple chalazia can be excised carefully, if necessary, 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 when sparing the lid marginal bridge tissue.

Poorly executed incisions, such as those transgressing the edge of the lid, may result in notching. Incisions that are too deep may cause cutaneous fistulae and scars. Inadequate curettage and drainage may lead to recurrences or the development of granulomata.

Finally, it is imperative to biopsy a recurrent chalazion to rule out a sebaceous cell carcinoma. If a biopsy is indicated, it may be performed by simply excising a section of the remaining edge of the lesion. It is important not to have the specimen processed as usual but, instead, to make a specific request to the pathologist to rule out sebaceous cell carcinoma and, in particular, to consider using fat stains.

Diet and Activity

Dietary modification has not been prospectively evaluated in the management of chalazion. In certain individuals, the advice given to patients with severe acne rosacea or acne vulgaris—namely, to avoid or decrease their ingestion of coffee, chocolate and highly refined foods, as well as fried foods and those containing saturated fats—may be appropriate.

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.

Prevention

Prophylaxis involves daily eyelid hygiene and massages. Heat and moisture are also critical to physiologically empty the glands.

The “4 fingers times 10” routine (see Conservative Measures) is often useful. An alternate method that is both effective and easy to perform is to apply warm moist compresses on the lids. The middle section of a clean paper towel or clean facecloth is shaped so as to look like a finger and then placed under running warm water. It is then used to gently massage the upper and lower eyelids in a horizontal motion to open up any blocked glands. Repeated use of the same washcloth or other porous material may enable fomite-mediated infection.

Using anti-dandruff shampoo on the eyebrows can also lessen the occurrence of skin particles causing blockages, especially in those who are prone to seborrhea.

The use of topical mild steroid or antibiotic drops may also help suppress the granulomatous inflammation. Finally, note that typical chalazia do occur more frequently in patients with immune disorders or acne rosacea and in individuals who have high exposure to ultraviolet (UV) radiation. Theoretically, therefore, chalazion formation could be reduced by managing these medical conditions and by limiting UV exposure through the use of sunglasses and hats.

Consultations

If a chalazion does not resolve with conservative management, referral to an ophthalmologist for follow-up care after 1 month is appropriate. For recurrent chalazia that have not been further evaluated, earlier referral is warranted.

Referral to a dermatologist may also be beneficial in helping to treat problems with acne rosacea or sebaceous dysfunction, as skin disorders can predispose to chalazia.

Long-Term Monitoring

Routine follow-up after 1 month should reveal resolution of the chalazion, with no swelling, redness or persistent lump. If the chalazion does not resolve, if a recurrence develops, or if additional symptoms arise, follow-up care with an ophthalmologist is advised. Any persistence of a nodule should lead the healthcare provider to review the diagnosis and entertain the possibility of a sebaceous cell carcinoma or another lid lesion.

For further evaluation and management, appropriate tissue specimens should be obtained for histologic study. Because sebaceous cell carcinoma is best evaluated using lipid stains, the pathologist should be alerted to perform tissue processing without dehydration, including frozen section. The specimen should still be prepared in formalin to avoid autolysis; formalin does not remove lipids, whereas alcohol baths used in paraffin sectioning do.

 

Medication

Medication Summary

Medical therapy for a chalazion 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 as low as 100 mg/week for 6 months may result in permanent biochemical change, with the sebaceous glands producing shorter-chain fatty acids, which are less likely to congeal and block gland orifices than longer-chain fatty acids are.

Although probably innocuous, topical antibiotics do not help this condition, which is not infectious. If there is a question regarding the possibility of infection within the lump, topical erythromycin ointment may be used after each application of hot compresses. Systemic tetracycline may be beneficial, but local drops are unlikely to help and are more likely to cause a contact dermatitis-type reaction. Long-term oral tetracycline, doxycycline, or metronidazole may be useful in the setting of chronic, recurrent chalazia.

Topical steroids can be helpful in minimizing inflammation and in reducing edema, thereby facilitating any drainage that may take place.

Antibiotics

Class Summary

Antibiotics are not indicated as treatment for an inflammatory lesion without evidence of an active infection. Significant benefit may be derived from low-dose, long-term oral therapy with tetracycline derivatives.

Tetracycline

The useful effects of tetracycline class antibiotics in patients with chalazia include altering the skin bacterial flora and altering lipids to produce shorter-chain fatty acids, thereby lowering the melting point and viscosity of sebaceous secretions and possibly preventing blockage of meibomian glands. Additional mechanisms of action may also benefit patients with acute and chronic chalazion, and long-term maintenance therapy may prevent recurrences.

Doxycycline (Doryx, Vibramycin, Adoxa, Doxy 100)

Doxycycline inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. It alters lipids to produce shorter-chain fatty acids, thereby lowering the melting point of sebaceous secretions and possibly preventing blockage of meibomian glands.

Minocycline (Minocin, Solodyn)

Minocycline alters lipids to produce shorter-chain fatty acids, lowering the melting point of sebaceous secretions and possibly preventing meibomian gland blockage.

Metronidazole (Flagyl, Metro)

When taken orally, metronidazole may benefit patients who are unable to take tetracyclines.

Bacitracin

Bacitracin prevents transfer of mucopeptides into the growing cell wall, which causes inhibition of bacterial cell wall synthesis.

Polymyxin B/bacitracin topical (Double Antibiotic, Polysporin)

Bacitracin prevents transfer of mucopeptides into the growing cell wall, which causes inhibition of bacterial cell wall synthesis. Polymyxin B damages bacterial cytoplasmic membrane and alters permeability, causing intracellular constituents to leak. Used to treat open excoriations and erosions.

Corticosteroids

Class Summary

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. Cicatricial complications may be avoided with judicious use of topical or injected corticosteroids.

Triamcinolone (Aristospan Intra-Articular, Kenalog)

The advantages of triamcinolone over other depot corticosteroids are decreased discomfort and reduced cost. Triamcinolone is used for inflammatory dermatoses responsive to steroids. This agent decreases inflammation by suppressing migration of PMNs and reversing capillary permeability. It acts to minimize scarring and inflammation. Injection of depo-steroids into the lid may raise intraocular pressure (steroid glaucoma) in susceptible individuals (steroid responders).

Methylprednisolone (DepoMedrol, Medrol, Solu-Medrol, A-Methapred)

Methylprednisolone decreases inflammation by suppressing migration of PMNs and reducing capillary permeability.

Dexamethasone (Baycadron, Dexamethasone Intensol)

Dexamethasone is used for various inflammatory diseases. It decreases inflammation by suppressing migration of PMNs and reducing capillary permeability.

 

Questions & Answers

Overview

What is a chalazion?

What is the pathogenesis of chalazia?

How do chalazia differ from hordeola?

Which conditions are risk factors for chalazia?

What is the global incidence and prevalence of chalazia?

How does the prevalence of chalazia vary by age?

How does the prevalence of chalazia vary by sex?

How does the prevalence of chalazia vary by race?

What is the prognosis of untreated chalazia?

What are the morbidities associated with chalazia?

What information about chalazia should patients be given?

What are the treatment options for chalazia?

When are complex procedures used for the treatment of chalazia?

Presentation

How does a chalazion present?

What should be the focus of the history when a chalazion is suspected?

What should be documented in the medical history of suspected chalazia?

Which physical signs are characteristic of chalazia?

How is a chalazion differentiated from a hordeolum?

How is the eyelid examined in the evaluation of chalazia?

What findings are significant in the evaluation of chalazia?

Which dermatologic findings are characteristic of chalazia?

What are the potential complications of chalazia?

DDX

Which conditions should be included in the differential diagnosis of chalazia?

What are the differential diagnoses for Chalazion?

Workup

How are chalazia diagnosed?

What is the role of lab studies in the diagnosis of chalazia?

What is the role of visual acuity and visual field testing in the diagnosis of chalazia?

Which histological findings are characteristic of chalazia?

What is the role of imaging studies in the diagnosis of chalazia?

Treatment

What are the treatment options for chalazia?

What is the role of Demodex folliculorum in the etiology of chalazia?

What are conservative treatment measures for chalazia?

How is the "4 fingers times 10" massage performed for the treatment of chalazia?

How are blocked glandular orifice opened in the treatment of chalazia?

What is the role of pharmacologic therapy in the treatment of chalazia?

Which pharmacologic therapies are effective for maintenance treatment of chalazia?

Which medications are alternatives to tetracyclines for the treatment of chalazia?

When are topical steroids indicated for the treatment of chalazia?

What is the role of steroid injections in the treatment of chalazia?

What is the efficacy of triamcinolone acetonide injections for the treatment of chalazia?

What are the possible complications of steroid injections for the treatment of chalazia?

Who should perform steroid injections and surgical drainage for the treatment of chalazia?

How is anesthesia administered for surgical intervention of chalazia?

How is surgery performed for the removal of chalazia?

When is an external surgical approach indicated for the treatment of a chalazion?

Which surgical intervention is indicated for larger or chronically neglected and excessively fibrotic chalazia?

What are the potential complications of surgery for chalazia?

How is a biopsy performed in the management of chalazia?

What are dietary modifications beneficial in the treatment of chalazia?

Which activity modifications are beneficial in the treatment of chalazia?

How are chalazia prevented?

Which specialists should be consulted in the treatment of chalazia?

What long-term monitoring is needed following treatment of chalazia?

Medications

Which medications are used in the treatment of chalazia?

Which medications in the drug class Corticosteroids are used in the treatment of Chalazion?

Which medications in the drug class Antibiotics are used in the treatment of Chalazion?