Chalazion

A chalazion is one of the most common inflammatory lesions of the eyelid. It is caused by obstruction of the Meibomian or Zeis glands, leading to granulomatous inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. 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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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Epidemiology and Etiology

Epidemiology

  • One 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 Hormones Hormones are messenger molecules that are synthesized in one part of the body and move through the bloodstream to exert specific regulatory effects on another part of the body. Hormones play critical roles in coordinating cellular activities throughout the body in response to the constant changes in both the internal and external environments. Hormones: Overview 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 Blepharitis Blepharitis is an ocular condition characterized by eyelid inflammation. Anterior blepharitis involves the eyelid skin and eyelashes, while the posterior type affects the meibomian glands. Often, these conditions overlap. Blepharitis
    • Eyelid trauma or surgery
    • Viral conjunctivitis Conjunctivitis Conjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis (can cause recurrent chalazia in children) 
    • Hordeolum Hordeolum A hordeolum is an acute infection affecting the meibomian, Zeiss, or Moll glands of the eyelid. Stasis of the gland secretions predisposes to bacterial infection. Staphylococcus aureus is the most common pathogen. Hordeolum (Stye) (chalazion may arise afterward)
  • Systemic factors:
    • Seborrheic dermatitis Seborrheic dermatitis Seborrheic dermatitis is a common chronic, relapsing skin disorder that presents as erythematous plaques with greasy, yellow scales in susceptible areas (scalp, face, and trunk). Seborrheic dermatitis has a biphasic incidence, occurring in two peaks: first in infants, then in adolescence and early adulthood. Seborrheic Dermatitis 
    • Rosacea Rosacea Rosacea is a chronic inflammatory disease of the skin that is associated with capillary hyperreactivity. This condition is predominantly seen in middle-aged women, and is more common in fair-skinned patients. Rosacea
    • Hyperlipidemia
    • Tuberculosis Tuberculosis Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis complex bacteria. The bacteria usually attack the lungs but can also damage other parts of the body. Approximately 30% of people around the world are infected with this pathogen, with the majority harboring a latent infection. Tuberculosis spreads through the air when a person with active pulmonary infection coughs or sneezes. 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 Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation distinguishes a chalazion from a hordeolum.
  • Location on the eyelid is dependent on which gland is obstructed:
    • Meibomian gland → inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation on the conjunctival portion 
    • Zeis gland → inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. 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 causes

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 Hordeolum A hordeolum is an acute infection affecting the meibomian, Zeiss, or Moll glands of the eyelid. Stasis of the gland secretions predisposes to bacterial infection. Staphylococcus aureus is the most common pathogen. Hordeolum (Stye): a localized infection arising from the Zeis gland, Moll gland, or Meibomian gland. Staphylococcus Staphylococcus Staphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora. 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 Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand, are due to sterile, granulomatous inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation and are not painful.
  • Blepharitis: an inflammatory condition of the eyelid margins; classified as posterior or anterior blepharitis Blepharitis Blepharitis is an ocular condition characterized by eyelid inflammation. Anterior blepharitis involves the eyelid skin and eyelashes, while the posterior type affects the meibomian glands. Often, these conditions overlap. 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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