Chalazion
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Chalazia commonly present as a nodule of an eyelid. It arises from obstruction of the sebaceous (oil glands) of the eyelid tarsal plate. It affects the upper eyelids more commonly than lower lids because there are more meibomian (sebaceous) glands in the upper lid. This condition affects both sex equally and occurs in all age group.
Disease Entity
Chalazion are differentiated from hordeolum (both external and internal); hordeolum result from acute purulent inflammation of eyelid glands. An external hordeolum (stye) involves the eyelash follicles; an internal hordeolum arises from bacterial infection of a meibomian gland. Another classification describes deep and superficial chalazia. While inflammation of a tarsal meibomian gland causes deep chalazion, inflammation of Zeis gland causes superficial chalazion.[1] Therefore, in simple terms, inflammation of the Gland of Zeis is hordeolum externum(stye) which can lead to a superficial chalazion(collar stud). And inflammation of the meibomian gland is hordeolum internum which can lead to a deep chalazion.
Disease
Chalazion is a chronic sterile lipogranuloma residing within eyelid that originates from an obstructed meibomian gland of the tarsal plates.
Etiology
Chronic granulomatous reaction in the eyelid induced by retained sebaceous secretions from meibomian gland.
Risk Factors
The strongest risk factors are blepharitis, rosacea, or prior chalazion. Other risk factors include Demodicosis (demodex mite infestation),[2] low serum vitamin A, gastrointestinal inflammation, and smoking.[3] More recently bortezomib, a first generation proteasome inhibitor for hematological malignancies has been associated with chalazia.[4]
General Pathology
Microscopic study shows chronic granulomatous inflammation compromised of multinucleated giant cells and epithelioid cells surrounding a lipid globule. Neutrophils, lymphocytes and plasma cells may are often present.
Pathophysiology
Meibomian glands are sebaceous glands located in the tarsal plate of eyelid. Their secretion includes polar and non-polar lipids, which are components of tear film.[5] If the outflow of these sebaceous secretions is obstructed, the oily secretions are retained and may leak into the adjacent tissue, which will in turn induce chronic granulomatous inflammatory response leading to formation of lipogranuloma.
Primary prevention
Regular massage and warm compresses can help in drainage of the sebaceous secretion and therefore decrease occurrence or recurrence of chalazion. Maintaining good lid hygiene may also be beneficial.
Diagnosis
Diagnosis is by clinical findings. Further workup for confirmation is usually not necessary except in recurrent cases where sebaceous gland carcinoma needs to be excluded.
History
Patient usually presents with gradually enlarging eyelid nodule, eyelid discomfort or even painful swelling if secondary infection occurs. Patients may have history of similar eyelid swelling in the past
Physical examination
On examination of the eyelid, a solitary, non-tender nodule is noted in the tarsal plate. Eversion of eyelid helps in identifying the lesion.
Clinical diagnosis
Clinical diagnosis is usually based on patient's history and appearance of the lesion.
Diagnostic procedures
Slit-lamp examination to assess the condition of the meibomian glands (which often show diffuse inspissation of yellowish contents from the eyelid margin orifices). The eyelid should be everted to exclude other pathologies, such as sebaceous carcinoma, and allow for appreciation of associated pyogenic granuloma.
Laboratory test
Recurrent or atypical chalazia should be sent for pathologic evaluation. Microscopy of the materials from a chalazion shows a lipogranulomatous reaction.
Differential diagnosis
Malignant or benign tumors such as sebaceous carcinoma or sebaceous hyperplasia; less commonly juvenile xanthogranuloma, basal cell, seborrheic keratosis, epithelial inclusion cyst or a retained foreign body can appear similar to a chalazion.[6]
Management
Small, asymptomatic chalazion can be left untreated. Conservative treatment including lid massage, warm compression and antibiotic-steroid eye drops or ointments can also be used. However, with administration of topical or local steroid agents, the intraocular pressure should be monitored and the treatment course should be limited. Persistent chalazion can be surgically incised.
Topical antibiotics eye drops are useful if the chalazion is associated with inflammatory conditions such as blepharitis.
Alternatives to conservative or surgical treatment includes injection of the lesion with either steroid or 5-flurouracil. Local injection leads to resolution in most cases; repeated injection can be given 1-2 weeks later if lesion persists. However, patients should be aware that intralesional steroid injection carries the risks of skin necrosis, subcutaneous fat atrophy, embolic visual loss, incomplete resolution and need for surgical removal, and skin hypo-pigmentation or hyper-pigmentation (particularly in patients with darker skin tones).
Medical therapy
Both standard and low dose systemic tetracyclines (such as doxycycline) can be considered in severe or recurrent cases.[7] There may be a role for topical antibiotics prophylaxis with macrolide antibiotics (such as erythromycin ointment or Azithromycin gel). Acute treatment with topical antibiotic-steroid drops or ointment. Topical lid hygiene with tea tree oil derived lid wipes, dilute hypochlorous acid spray, or mild soaps and water can be considered.
Surgery
Surgical treatment may be considered in case of unresolved chalazion or large and symptomatic chalazion. Incision and curettage is the treatment of choice.
Local anesthetic agent is injected to the area surrounding the lesion. Eyelid is then everted with special clamp and incision is made through conjunctiva. Contents of chalazion are curetted, and tarsus may be minimally resected if indicated. Since the operation is done at the inner side of eyelid, no scar will be seen over the anterior aspect of the lid.
Preferably, specimens obtained during the procedure should be sent to pathology.
Surgical follow up
Patient may be seen again in several weeks, or follow-up as required. The inflamed lid may still take several weeks to completely resolve.
Complications
Large chalazia can occasionally exert mass effect on cornea and result in astigmatism and blurred vision; Acute secondary infection leading to pain that may require incision and curettage.
Steroid injection may lead to local skin depigmentation or atrophy of skin.
Prognosis
Excellent prognosis is expected. Untreated chalazion can resolve spontaneously in weeks.
Additional Resources
- Boyd K, Pagan-Duran B. Chalazia and Stye. American Academy of Ophthalmology. EyeSmart/Eye health. https://www.aao.org/eye-health/diseases/chalazia-stye. Accessed March 07, 2019.
References
- ↑ Jordan, G. A., & Beier, K. (2023, July 31). Chalazion. Chalazion - StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK499889/
- ↑ Yam JC, Tang BS, Chan TM, Cheng AC. Ocular demodicidosis as a risk factor of adult recurrent chalazion. Eur J Ophthalmol. 2014;24(2):159-63.
- ↑ Nemet AY, Vinker S, Kaiserman I. Associated morbidity of chalazia. Cornea. 2011;30(12):1376-81.
- ↑ Fraunfelder FW, Yang HK. Association Between Bortezomib Therapy and Eyelid Chalazia. JAMA Ophthalmol. 2016;134(1):88-90.
- ↑ Butovich IA. Lipidomics of human Meibomian gland secretions: Chemistry, biophysics, and physiological role of Meibomian lipids. Prog Lipid Res. 2011;50(3):278-301.
- ↑ Ozdal PC, Codere F, Callejo S, Caissie AL, Burnier MN. Accuracy of the clinical diagnosis of chalazion. Eye (Lond). 2004;18(2):135-8.
- ↑ Wladis EJ, Bradley EA, Bilyk JR, Yen MT, Mawn LA. Oral Antibiotics for Meibomian Gland-Related Ocular Surface Disease: A Report by the American Academy of Ophthalmology. Ophthalmology. 2016;123(3):492-6.
- Khan JA, Doane JF, Grove AS Jr. Ophthal Plast Reconstr Surg. 1991;7(1):61-6. Review.
