Chalazion

A chalazion is 1 of the most common inflammatory lesions of the eyelid. It is caused by obstruction of the Meibomian or Zeis glands, leading to granulomatous inflammation and resulting in a firm, rubbery, slow-growing nodule that is typically non-tender. Diagnosis is based on history and physical exam findings. Most chalazia will resolve with conservative management.

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Epidemiology and Etiology

Epidemiology

  • 1 of the most common inflammatory lesions of the eyelid
  • Exact incidence and prevalence in the United States are unknown.
  • More common in adults (especially those aged 30–50 years) than in children (possibly due to higher levels of androgenic hormones and increased sebum viscosity)
  • Affects both genders equally

Etiology

Occurs due to gland blockage, which can be associated with:

  • Lifestyle factors: 
    • Poor lid hygiene
    • Stress (mechanism unknown)
  • Local factors:
    • Chronic blepharitis
    • Eyelid trauma or surgery
    • Viral conjunctivitis (can cause recurrent chalazia in children) 
    • Hordeolum (chalazion may arise afterward)
  • Systemic factors:
    • Seborrheic dermatitis 
    • Rosacea
    • Hyperlipidemia
    • Tuberculosis
    • Immunodeficiency
    • Malignancy (can be disguised as recurrent chalazia, especially in the elderly)

Pathophysiology and Clinical Presentation

Pathophysiology

  • A chalazion forms due to obstruction of Meibomian or Zeis glands.  
  • Lipid breakdown products accumulate and leak into the surrounding tissue, causing a granulomatous inflammatory response. Sterile inflammation distinguishes a chalazion from a hordeolum.
  • Location on the eyelid is dependent on which gland is obstructed:
    • Meibomian gland → inflammation on the conjunctival portion 
    • Zeis gland → inflammation along the lid margin
Sagittal cut of the upper lid featuring its internal structure

Anatomy of the eyelid: Note the locations of the Meibomian and Zeis glands, which are typically involved in the formation of a chalazion.

Image by Lecturio.
Chalazion

Visualization of a blocked Meibomian gland causing a chalazion

Image by BioDigital, edited by Lecturio

Clinical presentation

  • Slow-growing, rubbery nodule on the eyelid
    • If large enough, can compress the cornea and cause astigmatism
    • More common on the upper lid due to the increased number and length of Meibomian glands
  • Normally painless, but may cause mild tenderness if the lesion progresses to a large size
  • Increased tearing
  • Eyelid heaviness
  • Conjunctival erythema
  • Swollen preauricular lymph nodes may be present in cases of secondary bacterial infection.
Chalazion

Patient presenting with a chalazion on the left eyelid with mild swelling

Image: “Chalazion” by jd. License: Public Domain

Diagnosis and Management

Diagnosis

Diagnosis is clinical based on the history and physical exam.

  • Physical exam will show: 
    • Presence of a non-tender, firm, palpable nodule on the eyelid
    • Everting the eyelid may improve visualization.
  • Recurrent or persistent lesions should prompt further investigation: fine needle aspiration cytology or biopsy to rule out malignancy
  • Visual acuity and field testing may be necessary if a chalazion is large.

Management

  •  Conservative management:
    • Most will resolve without treatment.
    • Keep area clean.
    • Warm compresses
    • Lid massages
    • If the chalazion does not resolve within a couple of months, the patient may need a referral to ophthalmology. 
    • Systemic antibiotics are generally not necessary, but if a secondary infectious process is present, antibiotic options are:
      • Tetracycline
      • Doxycycline
      • Minocycline
      • Azithromycin
      • Metronidazole
  • Invasive treatment (for a persistent or large, symptomatic chalazion):
    • Steroid injection
    • Incision and drainage

Differential Diagnosis

  • Hordeolum: a localized infection arising from the Zeis gland, Moll gland, or Meibomian gland. Staphylococcus aureus is a common cause. Examination findings of a tender, erythematous, pus-filled nodule help establish the diagnosis. Management is generally conservative, though severe cases may require antibiotics or drainage. Chalazia, on the other hand, are due to sterile, granulomatous inflammation and are not painful.
  • Blepharitis: an inflammatory condition of the eyelid margins; classified as posterior or anterior blepharitis. Inflammation is seen at the inner portion of the eyelid or at the base of the eyelashes. Patients present with red, swollen, itchy eyelids or vision changes. Diagnosis is clinical, and management includes eyelid hygiene and conservative measures. Symptoms and physical exam differentiate this condition from a chalazion.
  • Sebaceous carcinoma: a rare malignancy of the sebaceous glands, such as the Meibomian and Zeis glands. Presents as a round, painless nodule of the eyelid. Diagnosis is made by biopsy of the lesion, and management requires surgical removal of the tumor. Distinguishing this from a chalazion may be difficult, and biopsy should be pursued for persistent lesions.

References

  1. Gosh, C., & Gosh, T. (2020). Eyelid lesions. In J. Givens (Ed.), UpToDate. Retrieved October 20, 2020, from https://www.uptodate.com/contents/eyelid-lesions
  2. Deschenes, J., & You, J.Y. (2019). Chalazion. In A.A. Dahl (Ed.), Medscape. Retrieved October 20, 2020, from https://emedicine.medscape.com/article/1212709-overview
  3. Kasper, D. L., Fauci, A. S., Longo, D.L., Bruanwald, E., Hauser, S. L., Jameson, J.L., (2007). Harrison’s principles of internal medicine (16th edition.). New York: McGraw Hill Education.

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