Chalazion (Meibomian Cyst)

Definition

A chalazion is a sterile, chronic granulomatous inflammatory lesion (lipogranuloma) of the meibomian gland (or occasionally the gland of Zeis) in the eyelid, caused by obstruction of the gland duct with retained lipid-rich sebaceous secretions. The retained material acts as a foreign body, triggering a granulomatous foreign-body inflammatory reaction.

Goldman-Cecil Medicine, p. 302
Kanski's Clinical Ophthalmology 10th ed., p. 54

Pathogenesis & Histology

The blocked meibomian gland secretion forms a collection that stimulates:

Lipogranulomatous inflammation - extracellular fat deposits
Surrounded by lipid-laden epithelioid cells and multinucleated giant cells
Background infiltrate of lymphocytes

Histopathology (Fig. A below): lipogranuloma with large pale epithelioid cells and well-demarcated empty spaces (fat dissolved out during processing)

Histopathology of chalazion showing lipogranuloma with empty fat spaces and surrounding epithelioid cells

Clinical appearance (Fig. B): painless, firm nodule in the upper or lower eyelid

Clinical photo of uninflamed chalazion presenting as a raised, reddish nodule on the upper eyelid

Associated Conditions

Condition	Relevance
Blepharitis	Commonly co-present
Acne rosacea	Associated with multiple/recurrent chalazia
Bortezomib (proteasome inhibitor for myeloma)	Predisposes to chalazia within 3 months of initiation
Sebaceous carcinoma	Must be excluded in recurrent lesions, especially in older patients

Symptoms & Signs

Symptoms: Acute or chronic eyelid lump, swelling, tenderness (can be painless or painful)

Critical sign: Visible or palpable, well-defined, subcutaneous nodule in the eyelid

Other signs:

Blocked meibomian gland orifice
Eyelid swelling and erythema
Focal tenderness
Associated blepharitis or acne rosacea
Lesion may drain mucopurulent material

Chalazion vs. Hordeolum

Feature	Chalazion	Hordeolum (Stye)
Nature	Sterile, chronic granulomatous	Acute bacterial abscess
Gland involved	Meibomian (± Zeis)	Meibomian (internal) / Zeis or Moll (external)
Pain	Painless or mildly tender	Painful
Organism	None (sterile)	Usually Staphylococcus spp.
Nodule	Well-defined, firm, non-mobile	Tender, may point at lid margin

Differential Diagnosis

Preseptal cellulitis - periorbital erythema, edema, warmth
Sebaceous carcinoma - recurrent chalazia, eyelid thickening, madarosis, chronic unilateral blepharitis in older patients
Pyogenic granuloma - benign, red, pedunculated conjunctival lesion
Forniceal foreign body - especially in contact lens wearers

Key clinical tip: If a chalazion recurs at the same lid position in an older patient, biopsy is mandatory to exclude malignancy (sebaceous carcinoma). - Kanski's Clinical Ophthalmology

Workup

History: Previous ocular surgery/trauma? Previous chalazia?
External examination: Palpate eyelid for nodule; look for rosacea
Slit lamp: Evaluate meibomian glands for inspissation, evert eyelid; assess for madarosis, poliosis, ulceration

Treatment

Step 1 - Conservative (all cases)

Warm compresses for at least 10 minutes 4x daily with gentle massage over the lesion
Most lesions resolve over days to weeks

Step 2 - Medical (if needed)

Topical antibiotic/steroid (e.g., neomycin/polymyxin B/dexamethasone ointment b.i.d. for 1-2 weeks)
Chronic low-dose doxycycline 20-50 mg p.o. daily to b.i.d. for multiple/recurrent chalazia or ocular rosacea (antibacterial + anti-inflammatory)

Step 3 - Procedural (failure after 3-4 weeks)

Option A: Incision and curettage (I&C)

Chalazion clamp applied with open side inside the eyelid
Vertical incision through conjunctival surface
Curettage of contents

Option B: Intralesional steroid injection

Triamcinolone 40 mg/mL mixed 1:1 with 2% lidocaine with epinephrine (0.2-1.0 mL total, depending on lesion size)
Alternatives: betamethasone combinations or dexamethasone sodium phosphate 4 mg/mL

Warning on steroid injection: Can cause permanent depigmentation or skin atrophy at the injection site - especially in dark-skinned individuals. Rarely, vigorous injection can cause retrograde intra-arterial infiltration with central retinal artery occlusion. Use with detailed patient counselling.

All removed specimens - send to pathology

Especially recurrent or atypical chalazia.

Follow-Up

Medical therapy: reassess only if lesion persists beyond 3-4 weeks
After I&C: reexamine as needed
The Wills Eye Manual, pp. 381-383
Kanski's Clinical Ophthalmology 10th ed., p. 54
Goldman-Cecil Medicine, p. 302

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