Diagnosis: Chalazion (with features of Internal Hordeolum)

Key Definitions (Wills Eye Manual, 6.2)

Differential Diagnosis to Consider

• Preseptal (periorbital) cellulitis - important to exclude: presents with eyelid erythema, tense edema, warmth, and tenderness, but no proptosis, no motility restriction, no pain with eye movement
• Orbital cellulitis - more serious: adds proptosis, restricted eye movement, pain on movement - exclude clinically
• Sebaceous gland carcinoma - suspect if recurrent, especially in older patients with madarosis (lash loss)
• Allergic reaction - typically sudden onset, nontender, bilateral, itchy
• Pyogenic granuloma - fleshy, vascular conjunctival lesion sometimes associated with chalazia

Workup

1. History: Any prior chalazia or eyelid surgeries? Duration of lesion? Fever or systemic illness (to rule out cellulitis/abscess)?
2. External exam: Palpate lid for a discrete nodule. Check for acne rosacea.
3. Slit-lamp exam: Evert eyelid to inspect meibomian glands; look for madarosis or ulceration suggesting malignancy.
4. If fever, rapid spread, or systemic signs are present: rule out preseptal cellulitis (may need blood work, CT orbit).

Treatment

Step 1 - Conservative (First-line for all cases)

• Warm compresses for at least 10 minutes, 4 times daily (q.i.d.), with gentle massage over the lesion
• This softens inspissated meibomian secretions and promotes drainage

Step 2 - Topical Antibiotics / Antibiotic-Steroid

• Hordeolum: topical antibiotic ointment (e.g., bacitracin, tobramycin, or erythromycin ointment b.i.d. for 1-2 weeks)
• Chalazion: topical antibiotic/steroid combination (e.g., neomycin/polymyxin B/dexamethasone ointment b.i.d. for 1-2 weeks)
• If spreading cellulitis develops: systemic antibiotics (oral amoxicillin-clavulanate or doxycycline)

Step 3 - If worsening (Hordeolum)

• Incision and drainage (I&D): refer to ophthalmologist; manage associated preseptal cellulitis if present

Step 4 - If chalazion persists after 3-4 weeks of medical therapy

• Intralesional corticosteroid injection: triamcinolone 40 mg/mL mixed 1:1 with 2% lidocaine with epinephrine (0.2-1.0 mL total, depending on lesion size)
  • ⚠️ Important warning: In dark-skinned individuals (as appears to be the case here), steroid injection carries risk of permanent depigmentation or skin atrophy at the injection site. This risk must be explicitly discussed with the patient before proceeding.
• Incision and curettage (I&C): surgical option via the inner (conjunctival) surface of the eyelid under local anesthesia

Step 5 - Recurrent chalazia

• Low-dose oral doxycycline 20-50 mg once or twice daily for its anti-inflammatory and antibacterial properties (especially if associated with ocular rosacea or meibomian gland dysfunction)
• All excised chalazia (especially recurrent/atypical ones) should be sent for histopathology to exclude sebaceous carcinoma

Follow-Up

• No routine follow-up needed if conservative therapy is started - re-evaluate only if lesion persists beyond 3-4 weeks
• Post-procedure patients are followed as needed

Clinical note: Given the significant swelling and erythema seen in these images, assess the patient for fever, tenderness, and eyelid induration. If cellulitis cannot be excluded clinically, consider prompt ophthalmology referral or systemic antibiotics empirically. This is not a simple painless chalazion - the acute inflammatory appearance suggests an infected hordeolum or early preseptal cellulitis that requires more active management.