What is a chalazion and how do you treat it? The many faces of chalazia.
Contributors: BCK Patel MD, FRCS, Jay Patel BSC, Raman Malhotra FRCS
Photographer: BCK Patel MD, FRCS
Posted December 19, 2021
Definition of a Chalazion: Traditionally, a chalazion is defined as the painless lump that develops on the eyelid, caused by the blockage of a Meibomian gland. These lumps enlarge slowly as the blocked Meibomian gland allows the lipogranulomatous material to expand within and eventually beyond the confines of the Meibomian gland. Initially, these lesions are rubbery and may become firm over time. Secondary inflammation or infection can make these lesions become tender to the touch. It is questionable if there is an inciting incidence of infection of the Meibomian glands leading to the formation of a chalazion.
When an area of inflammation is seen along the eyelid margin or within an eyelid, the terms stye, chalazion, internal hordeolum and external hordeolum are frequently used interchangeably. This is incorrect as each term describes a specific type of lesion and appearance.
Etymology: The Greek word “khalaza” means a “small knot”. The diminutive of “khalaza” is “khalazion”. Singular: “Chalazion”; Plural: “Chalazia” or “Chalazions”.
Synonyms: Tarsal cyst, Meibomian cyst, External hordeolum (see below), Internal hordeolum (see below)
Natural History: When a Meibomian gland opening becomes blocked, the sebaceous material within the gland expands causing a painless swelling, which is called a chalazion. They grow slowly and are initially painless. As the inflammation may spread to the surrounding tissues and secondary infection may occur, local tenderness may develop. Without intervention, chalazia may grow slowly over weeks to months and may become firm. They eventually resolve but can take weeks to months to resolve. When they become inflamed with or without infection and burst through to the external (skin) or internal (tarsal conjunctiva) surface, they resolve more promptly.
Chalazia are seen in childhood and also in adults in the 30 – 50 age group. Underlying conditions like acne rosacea and blepharitis can predispose to chalazia. Contrary to popular belief, use of contact lenses and use of makeup have not been associated with an increased incidence of chalazia. The wearing of masks during the Covid-19 pandemic has led to an increased incidence of chalazia, thought to be due to the drying effect of the flow of air behind the masks to the eyelid margins. A decrease in the use of masks has been shown to reduce the incidence of chalazia. A mechanical ptosis will occur with larger chalazia. Chalazia can also make it difficult to wear contact lenses because of the pressure of the enlarged glands on the cornea. In the lower eyelids, a mechanical ectropion may occur and can cause epiphora. Chronic chalazia may develop secondary calcification, which is seen in older patients. Development of malignancy with an initial formation of a chalazion is very rare.
External Hordeolum: Classically, the term “external hordeolum” is reserved for styes which are infections of the sebaceous oil glands (glands of Zeis) which open into the eyelash follicle. However, the term “external hordeolum” has also been used when a chalazion becomes infected and/or inflamed and erodes through the skin.
Internal Hordeolum: When a Meibomian gland cyst (chalazion) becomes inflamed and points posteriorly to the tarsal conjunctiva or erodes through the tarsal conjunctiva, the lesion is often termed an “internal hordeolum”.
Internal hordeola can cause local exuberant inflammation with a secondary pyogenic granuloma.
Meibomian Glands: Meibomian glands (also called tarsal glands) are glands within the tarsus of the upper eyelid and the lower eyelid. There are up to 30 such glands in the upper eyelid and 25 in the lower eyelid. They produce an oily substance called meibum which reduces the rate of evaporation of the tear film. They are exocrine glands, meaning they have ducts that secrete their contents via ducts that open at the eyelid margin. They are also holocrine glands because the secretions result from lysis of the secretory glands, thereby releasing the oily substance into the duct. Meibomian glands produce the oily substance called “meibum”, which forms the outer layer of the tear film and reduces evaporation of the aqueous component. Meibum also keeps the aqueous component from spilling over the edge of the eyelid by forming a film on the tear film and at the edge of the eyelid. Meibum also allows eyelids to shut into airtight closed units.
Etymology: Meibomian glands are named after Heinrich Meibom (1638 – 1700) who was a German physician who studied in France, Germany, Italy and England and went on to become a professor of medicine, and also a professor of history and poetry. Besides his medical treatises, he is also known for his Latin poetry.
Differential diagnosis of Chalazia:
Sebaceous gland carcinoma
Nodular basal cell carcinoma
Histopathology of Chalazia: histopathology of a chalazion will reveal a lipogranulomatous reaction with multinucleated giant cells, neutrophils and lymphocytes with lipid vacuoles.
Management of Chalazia: It should be noted that a major review has shown that the traditionally accepted treatments for “internal hordeola” of warm compresses, over-the-counter topical medications, lid scrubs, prescribed antibiotics, steroids and eyelid massages have not been shown to be effective as non-surgical interventions. We present below what we have used successfully in our patients.
Acute Presentation: Most patients will present with a non-tender lump on an eyelid. The complaint is often one of cosmesis rather than discomfort or trouble with vision. However, a large chalazion can cause pressure on the cornea, creating astigmatism. Chalazia can also be in the line of sight when central.
Chalazia presenting early have lipogranulomatous material within the Meibomian gland. Traditionally, application of “warm soaks” four to five times a day, with or without the application of an antibiotic ointment or an antibiotic-steroid ointment is prescribed. Heat may be applied to the mass in any number of ways, including warm face-cloths, heated rice-pods, etc. The emphasis should be on pressure on the enlarged Meibomian gland. It is the pressure that allows the softening of the contents and possible egress of the material out through the “blocked” Meibomian gland orifice. Systemic antibiotics are rarely indicated for simple chalazia without evidence of cellulitis. Even when there is evidence of infection within the Meibomian gland, incision and curettage together with the application of topical antibiotic ointment will resolve the issue.
Chronic Chalazia: once chalazia have been present for several weeks, they become more firm. Although all chalazia will eventually resolve if left alone, patients are understandably keen to resolve them sooner. In such patients, incision and curettage is the best approach. This is usually performed via the conjunctival approach although, when the chalazion presents with an anterior break in the skin, it is reasonable to drain the chalazion through the anterior approach. When incising the mass from the tarsal surface, it is important to make the incisions vertically and not horizontally as some textbooks portray. There is no reason to make a crucifix incision and excise portions of the tarsus, as has also been promoted in ophthalmic textbooks. It is important to drain all the involved glands. Frequently, there will be more than one Meibomian gland involved. We use a specific technique to drain all glands that may be inspissated once the incision and curettage has been performed. This is demonstrated in the attached video.
Beware chronic chalazia and chalazia in older patients: sebaceous carcinoma can present with the appearance of a chalzion or multiple chalazia. The eyelid will have a yellowish appearance and the patient will not experience any discomfort. The slow growth with lack of pain and any associated loss of lashes should alert the physician to obtain a full-thickness biopsy of the eyelid and submit it fresh to the ophthalmic pathologist for appropriate staining, looking for evidence of sebaceous carcinoma.
Chronic chalazia with pyogenic granuloma: sometimes, with posterior perforation of a chalazion, a pendulous mass will present. There may be little material within the affected Meibomian gland.
Chalazia with cellulitis: in children, single or multiple chalazia can enlarge, become secondarily infected and cause a preseptal cellulitis. Indeed, whenever a child is seen with a cellulitis, the eyelids should be examined to palpate for any underlying chalazia. With appropriate treatment of the chalazia, the cellulitis will settle.
Intralesional steroid injection of chalazia: in early, soft chalazia, simple intralesional steroid injection will result in resolution of more than 50% of chalazia. With any chronic, firm or multiple chalazia, it is helpful to incise, drain and inject the surrounding tissues with intralesional steroids to enhance the resolution of the inflamed tissues with associated fibrosis.
Incision and Curettage: Patients who do not respond to topical ointments and warm soaks or where the lesions are chronic, large or multiple, incision and curettage is performed.
- Topical xylocaine drops or gel
- 11 Bard Parker blade
- 2% lidocaine with epinephrine on a 30 or 32 gauge needle
- Monopolar cautery
- Chalazion clamp
- Chalazion scoop
- Dexamethasone 4 mg/ml injection
- Eye patches
- Westcott scissors and 0.5 mm forceps may be needed
- Soak the conjunctival surface with topical xylocaine drops or gel
- Evert the eyelid
- Apply the Gate theory (tapping, massage, rubbing of hands, arms, legs, etc) to reduce the perception of discomfort during the injection of local anesthetic
- Infiltrate the lesion with local anesthetic
- Apply the chalazion clamp and evert the eyelid
- Incise vertically over the affected Meibomian gland
- Curette the contents with a chalazion scoop
- Apply pressure to the treated and surrounded glands (see video) to ensure any other affected glands are also drained
- If there is a bleed, simple local cautery may be applied although this is rarely needed
- Some people apply carbolic acid to the cavity: we have not used this in our patients
- The eyelid will ooze for a few minutes: simple pressure will resolve this
- Application of ointment and a monocular occlusive dressing may be used
- When a chalazion is pointing anteriorly or has burst through the anterior surface of the eyelid, it is reasonable to perform curettage via the anterior of the eyelid
- Any granulomatous tissue is removed with sharp dissection
A chronically blocked Meibomian gland can result in a firm nodule in the eyelid. By using the term “chronic chalazion”, the firmness and chronicity of such lesions can be recognized. These lesions require incision, curettage, injection with steroids and postoperative warm soaks. Resolution takes weeks. Also send tissue for histopathology if the lesion is showing no signs of resolution and has been recurrent or there are loss of lashes.
The many faces of chalazia:
- Jordan GA, Beier K. Chalazion. StatPearls, Treasure Island (FL): StatPearls Publishing. Aug 2021. https://pubmed.ncbi.nlm.nih.gov/29763064/ PMID:29763064
- WillmannD, Guier CP, Patel BCK,, Melanson SW. Stye. StatPearls, Treasure Island (FL): StatPearls Publishing. Aug 2021. https://pubmed.ncbi.nlm.nih.gov/29083787/ PMID:29083787
- Lindsley K, Nichols JJ, Dickersin K. Non-surgical interventions for acute internal hordeolum. Cochrane Database Syst Rev 2017 Jan 9;1(1):CD007742 PMID:28068454