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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.

Last updated: 15 May, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Epidemiology and Etiology

Epidemiology

  • One of the most common inflammatory lesions of the eyelid
  • Exact incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency and prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency 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 Types and increased sebum Sebum The oily substance secreted by sebaceous glands. It is composed of keratin, fat, and cellular debris. Infectious Folliculitis viscosity)
  • Men and women are affected 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 Viral Conjunctivitis 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 Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) 
    • 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 Immunodeficiency Chédiak-Higashi Syndrome
    • Malignancy Malignancy Hemothorax (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 Sterile Basic Procedures 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 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).
  • 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 Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor

  • Slow-growing, rubbery nodule on the eyelid
    • If large enough, can compress the cornea Cornea The transparent anterior portion of the fibrous coat of the eye consisting of five layers: stratified squamous corneal epithelium; bowman membrane; corneal stroma; descemet membrane; and mesenchymal corneal endothelium. It serves as the first refracting medium of the eye. Eye: Anatomy and cause astigmatism Astigmatism Unequal curvature of the refractive surfaces of the eye. Thus a point source of light cannot be brought to a point focus on the retina but is spread over a more or less diffuse area. This results from the radius of curvature in one plane being longer or shorter than the radius at right angles to it. . Refractive Errors
    • 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 Lymph The interstitial fluid that is in the lymphatic system. Secondary Lymphatic Organs nodes may be present in cases of secondary bacterial infection.
Chalazion

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

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 Needle aspiration Using fine needles (finer than 22-gauge) to remove tissue or fluid specimens from the living body for examination in the pathology laboratory and for disease diagnosis. Peritonsillar Abscess cytology or biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma to rule out malignancy Malignancy Hemothorax
  • Visual acuity Visual Acuity Clarity or sharpness of ocular vision or the ability of the eye to see fine details. Visual acuity depends on the functions of retina, neuronal transmission, and the interpretative ability of the brain. Normal visual acuity is expressed as 20/20 indicating that one can see at 20 feet what should normally be seen at that distance. Visual acuity can also be influenced by brightness, color, and contrast. Ophthalmic Exam 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 Infectious Febrile Infant process is present, antibiotic options are:
      • Tetracycline Tetracycline A naphthacene antibiotic that inhibits amino Acyl tRNA binding during protein synthesis. Drug-induced Liver Injury
      • Doxycycline
      • Minocycline Minocycline A tetracycline analog, having a 7-dimethylamino and lacking the 5 methyl and hydroxyl groups, which is effective against tetracycline-resistant staphylococcus infections. Tetracyclines
      • Azithromycin Azithromycin A semi-synthetic macrolide antibiotic structurally related to erythromycin. It has been used in the treatment of Mycobacterium avium intracellulare infections, toxoplasmosis, and cryptosporidiosis. Macrolides and Ketolides
      • Metronidazole Metronidazole A nitroimidazole used to treat amebiasis; vaginitis; trichomonas infections; giardiasis; anaerobic bacteria; and treponemal infections. Pyogenic Liver Abscess
  • 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 aureus Staphylococcus aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Brain Abscess 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: Anatomy, are due to sterile Sterile Basic Procedures, 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 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: 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 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 is seen at the inner portion of the eyelid or at the base of the eyelashes. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present with red, swollen, itchy eyelids Eyelids Each of the upper and lower folds of skin which cover the eye when closed. Blepharitis or vision Vision Ophthalmic Exam 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 Malignancy Hemothorax 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 Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma of the lesion, and management requires surgical removal of the tumor Tumor Inflammation. Distinguishing this from a chalazion may be difficult, and biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma 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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