AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

A chalazion (Greek for hailstone) is a lipogranuloma of either a meibomian gland or a Zeis gland. When the former is involved, the lid nodule is characteristically hard and painless lid nodule; with the latter, it is marginal or superficial.

Pathophysiology

Lipid breakdown products, possibly from bacterial enzymes (as free fatty acids) or from retained sebaceous secretions, leak into the surrounding tissue and incite a granulomatous inflammatory response. The resulting mass of granulation tissue and chronic inflammation (with lymphocytes and lipid-laden macrophages) distinguishes a chalazion from an internal or external hordeolum, which is primarily an acute pyogenic inflammation with polymorphonuclear leucocytes and necrosis with pustule formation. However, one condition can result in the other because of their close proximity.

On clinical examination, the single, nontender, firm nodule (or, in rare cases, multiple nodules) is located deep within the lid or the tarsal plate, whereas a hordeolum is more superficial and is typically centered on an eyelash. Eversion of the lid may reveal the dilated meibomian gland and chronic inspissation of adjoining glands. With judicious pressure on the lid, the thick secretions can be seen extruding like toothpaste, resulting in tear debris.

Frequency

United States

Chalazia are common, but the exact incidence or prevalence is unknown.

International

No data about the prevalence or incidence are available.

Mortality/Morbidity

Acute inflammatory exacerbation can result in a rupture anteriorly (through the skin) or posteriorly (through the conjunctiva), forming a granuloma pyogenicum.

Race

No information about prevalence or incidence with respect to race is available.

Sex

• Male and females seem equally affected, but 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.

Age

Chalazia occur in all age groups.

• Chalazia are more common in adults than in children, as androgenic hormones increase sebum viscosity.
• Although they are uncommon at extremes of age, pediatric cases may be encountered.
• 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.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Patients usually present with a short history of recent lid discomfort, followed by acute inflammation (eg, redness, tenderness, swelling). They frequently have a long history of previous similar occurrences, because chalazia tend to recur in predisposed individuals.

Physical

Chalazia are more common on the upper lid than on the lower lid because of the increased number and length of meibomian glands present on the upper lid.

Chronic inspissation of the meibomian secretions may be apparent as meibomian gland dysfunction. This condition is characterized by pressure on the eyelids that produces copious toothpaste-like secretions instead of the normal small amount of clear, oily secretion. Sebaceous dysfunction and obstruction elsewhere (eg, comedones, oily face) are the only associated features or specific general findings.

Rosacea is a frequent associated finding.  When present, rosacea demonstrates very specific findings, such as facial erythema; telangiectatic and spider nevi on the malar, nasal, and lid skin; and rhinophyma.

Causes

Chalazia may arise spontaneously due to blockage of a gland orifice or due to an internal hordeolum. Chalazia are associated with seborrhea, chronic blepharitis, and acne rosacea.

Poor lid hygiene is occasionally associated with chalazia, although its causal role needs to be established. Although stress is often apparently associated with chalazia, it has not been proven as a cause, and the mechanism by which stress acts is unknown.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Clinical findings and responses to therapy are usually specific.
• 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 resulting in an increased melting point. This finding possibly accounts for the blockage of secretions.
• Bacterial cultures are usually negative. However, Staphylococcus aureus, Staphylococcus albus, or other cutaneous commensal organisms can be isolated. Propionibacterium acnes may be present in the glandular contents.

Imaging Studies

• Infrared photographic imaging of the meibomian glands can demonstrate abnormally dilated and inspissated secretions, which are visible on the tarsal surface of the everted lid.

Other Tests

• Pressure directly over the tarsal plate of the lid will result in the extrusion of lipids, especially of thick viscous material with meibomian gland dysfunction.

Histologic Findings

Histology reveals a chronic granulomatous reaction with numerous lipid-filled, Touton-type giant cells. Typically, the nuclei of these cells are arranged around the periphery of a central foamy cytoplasmic area that contains the ingested lipid material. Other typical mononuclear cells (eg, lymphocytes, macrophages) also may occur around the periphery.

In the event of secondary bacterial infection, an acute necrotic reaction with polymorphonuclear cells may ensue. Destruction of the fibrocartilage of the tarsal plate may be evident. Foreign bodies (eg, embedded polymethyl methacrylate [PMMA] contact lenses) in the tarsal plate have been encountered in chronic chalazia.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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.

Drug Category: Antibiotics

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

Drug Category: 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.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Routine follow-up at approximately 1 month should reveal resolution of the problem, with no swelling, redness, or persistent lump. Any persistence of a nodule suggests the diagnosis included not simply a chalazion but also sebaceous cell carcinoma or other lid lesion.
• For further evaluation and management, appropriate specimens of tissue should be obtained for histologic evaluation.
• • Because sebaceous cell carcinoma is best evaluated by using lipid stains, alert the pathologist to perform tissue processing without dehydration (ie, frozen section).
  • The specimen should still be prepared in formalin to avoid autolysis; it is not the formalin that removes the lipid, but rather, the alcohol baths used in paraffin sectioning.

Transfer

• Urgent transfer to an experienced orbital and/or ophthalmic plastic surgeon is mandatory after biopsy results are documented or if the clinical findings suggest sebaceous cell carcinoma.

Deterrence/Prevention

• Prophylaxis involves frequent regular massage of the eyelids. Massage, heat, and moisture are critical to help empty the glands.
• Instruct the patient about the "4 fingers times 10" routine, as follows:
• • At the end of a bath or shower, work up a lather on clean hands by using warm water and a drop of baby shampoo. (Baby shampoo does not sting if it gets into the eye.)
  • Close both eyes, and cover the lashes and both the upper and lower eyelids by using the index finger.
  • Vigorously massage the eye by making horizontal to-and-fro movements. Count each movement until 10 movements have been completed; this is the "10" part of the "4 fingers times 10" routine.
  • Repeat the entire procedure by using the middle finger, then the ring finger, then the little finger; this is the "4 fingers" part of the "4 fingers times 10" routine.
  • Rinse off the remaining shampoo.
• The use of topical mild steroid and/or antibiotic drops may help suppress the granulomatous inflammation.
• • An alternate method is to use a warm, moist compress. This simple method has the advantage of being effective and easy to perform.
  • Using a clean face towel, shape the middle section so it looks like a finger, and place it under running warm water.
  • After this "finger" of the towel has cooled off, use it to gently massage the upper and lower eyelids in a horizontal motion to open up any blocked meibomian glands.

Complications

• Improperly drained marginal chalazia can result in notching, trichiasis, and loss of lashes.
• • Biopsy is required to rule out malignancy in cases of recurrent chalazia or those appearing atypical.
  • Alert the pathologist of suspected sebaceous cell carcinoma and request frozen sections and lipid stains.
• Astigmatism may result when the lid mass distorts the corneal contour.
• Partially drained chalazia can result in large masses of granulation tissue prolapsing onto the conjunctiva or skin.

Prognosis

• Patients receiving therapy usually have an excellent outcome.
• New lesions often occur, and inadequate drainage may result in a local recurrence.
• Untreated chalazia occasionally drain spontaneously, but they are more likely than treated chalazia to persist with intermittent acute inflammation.

Patient Education

• Instruct patients about the importance of adequate lid hygiene and general health measures (eg, rest, stress management, proper diet) in maintaining good skin function. Explain that the lesions are benign, but meticulous lid hygiene and dedication may be required as preventive measures.
• The following points (in decreasing order of importance) are important:
• • Gentle but firm and vigorous massage to promote drainage of the meibomian glands
  • Warmth to help melt the viscous lipids
  • Water to remove the secretions collecting on the lid margin
  • Use of baby shampoo, which does not sting if it gets into the eye
• More complex procedures may be preferred.
• • An example is the use of diluted baby shampoo on a cotton wool 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.
• 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

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Recurrent chalazia, especially if they recur despite previous successful drainage in the same location, must be considered malignant sebaceous cell carcinoma. Prompt biopsy with frozen-section histologic study is warranted.
• Poorly executed incisions (eg, those transgressing the edge of the lid) result in notching. Incisions that are too deep may result in cutaneous fistulae and scars.
• Intralesional corticosteroid injections may result in cosmetically unacceptable loss of skin pigmentation or inadvertent injections into the globe. In predisposed individuals, the corticosteroid may result in an elevation of intraocular pressure.
• Inadequate curettage and drainage may result in recurrences or the development of granulomata.

Special Concerns

• Occasionally, patients present with profound concern for the causal factors for lid inflammation, including chalazia. These individuals may have major anxiety because of misinformation that Demodex folliculorum may have caused severe infestation, resulting in the lid disease.
• No evidence suggests that Demodex species cause lid disease; this ubiquitous parasite appears to be a harmless commensal organism, but it has been implicated in mange in dogs.
• Treatment of demodicosis includes the application of ointment at night to the eyes, a practice that results in the parasite being smothered.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Ben Simon GJ, Huang L, Nakra T, Schwarcz RM, McCann JD, Goldberg RA. Intralesional triamcinolone acetonide injection for primary and recurrent chalazia: is it really effective?. Ophthalmology. May 2005;112(5):913-7. [Medline].
• Gershen HJ. Chalazion. In: Master Techniques in Ophthalmic Surgery. Baltimore: Williams and Wilkins; 1995:370-3.
• Mansour AM, Chan CC, Crawford MA, Tabbarah ZA, Shen D, Haddad WF, et al. Virus-induced chalazion. Eye. Feb 2006;20(2):242-6. [Medline].
• Ozdal PC, Codere F, Callejo S, Caissie AL, Burnier MN. Accuracy of the clinical diagnosis of chalazion. Eye. Feb 2004;18(2):135-8. [Medline].
• Rosas Vasquez E, Campos Maocias P, Ocha Tirado JG. Chloracne in the 1990s. Int J Dermatol. 1966;35:643-645.
• Shiramizu KM, Kreiger AE, McCannel CA. Severe visual loss caused by ocular perforation during chalazion removal. Am J Ophthalmol. Jan 2004;137(1):204-5. [Medline].
• Soil DB, Wisnlow R. Surgery of the eyelids. In: Tasman W, Jaeger EA, eds. Duane's Foundations of Clinical Ophthalmology. Vol 5. JBL; 1999:56-9.
• Wessels IF. Chalazion. In: Fraunfelder FT, Roy FH, eds. Current Ocular Therapy. Philadelphia: W. B. Saunders; 2000:423-5.
• Wessels IF, Wessels GF. Lidocaine-prilocaine cream for local-anesthesia chalazion incision in children. Ophthalmic Surg Lasers. Jun 1996;27(6):431-3. [Medline].

Article Last Updated: Aug 3, 2007