Chalazion Treatment & Management

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 1 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. ^{[1, 11]} Intralesional steroid injection may be used for small lesions and lesions that are close to the lacrimal apparatus. Antibiotics usually are 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 management of chalazia includes warm compresses and lid hygiene. ^{[1, 12, 13]} 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 2 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).

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 often is very effective, particularly in the presence of oculocutaneous acne rosacea. Weekly pulse therapy is effective, as is maintenance therapy administered 1 week per month. Some clinicians recommend year-round treatment for severe recurrent cases, often taking a 1-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. ^[14]

A study by Ben Simon et al compared triamcinolone acetonide injections with incisions and curettage in 94 patients with chalazion. ^[15] 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, ^[16] 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. ^[17] 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. ^[18] Injection and removal of chalazia may create cosmetic morbidity. ^[19]

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.

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.

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.

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.

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.