Chalazion

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, 2]}

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.

Chalazia form when lipid breakdown products, possibly from bacterial enzymes or retained sebaceous secretions, leak into surrounding tissue and incite a granulomatous inflammatory response. ^[3]  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 usually is 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 usually are 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 primarily is 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. ^[4] However, 1 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.

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

• Poor lid hygiene (the precise causal role has not yet been established)
• Seborrheic dermatitis
• Rosacea
• Chronic blepharitis
• 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 ^[5]

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

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 also are 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.

In the pediatric population, Hispanic/Latino patients may develop chalazion at a higher rate than non-Hispanic/Latino patients. Native Americans and Asians may develop chalazion at a higher rate than Caucasians. ^[6]   

Conservative management facilitates resolution of chalazia, and patients receiving therapy usually have an excellent outcome. ^[1] Untreated chalazia occasionally drain spontaneously but are more likely to persist with intermittent acute inflammation compared with 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 ^[1] :

• 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 ^[7]

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.