Chalazoin

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Here is a thorough overview of chalazion based on multiple ophthalmology and primary care textbooks.

Chalazion (Meibomian Cyst)

Definition

A chalazion is a sterile, chronic granulomatous inflammatory lesion (lipogranuloma) of the meibomian gland (or occasionally the gland of Zeis), caused by obstruction and retention of lipid-rich sebaceous secretions within the eyelid. It is distinct from a hordeolum (stye), which is an acute bacterial abscess.

Goldman-Cecil Medicine, p. 302
Wills Eye Manual, p. 381

Pathogenesis

The retained lipid-rich material acts as a foreign body, triggering a lipogranulomatous foreign-body inflammatory reaction. Histopathology shows:

Extracellular fat deposits (appear as clear spaces after processing dissolves the fat)
Lipid-laden epithelioid cells and multinucleated giant cells
Surrounding lymphocytes

Histopathology - lipogranuloma:

Chalazion histopathology showing lipogranuloma with epithelioid cells and fat spaces

Kanski's Clinical Ophthalmology 10th ed., p. 54

Associated conditions:

Blepharitis (commonly present)
Acne rosacea (associated with multiple/recurrent chalazia)
Bortezomib (proteasome inhibitor used in myeloma) can predispose to chalazia within 3 months of starting treatment

Key warning: A recurrent chalazion in the same lid position - especially in older patients - must be biopsied to exclude sebaceous carcinoma masquerading as a chalazion.

Clinical Features

Bilateral chalazia in upper eyelids (clinical photo):

Bilateral chalazia showing red, inflamed swellings on both upper eyelids

Symptoms

Gradual onset of a painless or mildly tender eyelid lump (subacute/chronic form)
Acute form: localized cellulitis and sterile inflammation; if secondarily infected, becomes an internal hordeolum

Signs

Feature	Description
Critical	Well-defined, palpable subcutaneous nodule within the tarsal plate
Meibomian gland	Blocked orifice, inspissated secretions may be visible
Associated	Eyelid swelling, erythema, focal tenderness, blepharitis, acne rosacea
Possible	Conjunctival granuloma, or lesion pointing/draining mucopurulent material

Differential Diagnosis

Condition	Key distinguishing feature
Hordeolum (stye)	Acute, painful, bacterial; external (gland of Zeis) or internal (meibomian gland)
Sebaceous carcinoma	Recurrent chalazion same spot; madarosis, eyelid thickening, chronic unilateral blepharitis in older patient
Preseptal cellulitis	Diffuse eyelid/periorbital erythema, edema, warmth
Pyogenic granuloma	Deep-red, pedunculated conjunctival lesion, often post-chalazion/surgery
Forniceal foreign body	Eyelid swelling, history of contact lens use or trauma

Wills Eye Manual, p. 382

Workup

History - prior chalazia, ocular surgery, trauma, medications (bortezomib)
External examination - palpate eyelid for nodule; inspect for madarosis or ulceration
Slit lamp - evert eyelid, evaluate meibomian gland inspissation; assess for signs suggesting malignancy
Screen for rosacea (look at skin, check for telangiectasias)

Treatment

Step 1 - Conservative (first-line)

Warm compresses for at least 10 minutes 4x daily with gentle massage over the lesion
At least 1/3 resolve spontaneously - observation alone is appropriate if improving
Expression: compression between two cotton-tipped applicators can express contents of a fresh, superficial lesion

Step 2 - Medications

Topical antibiotic/steroid (e.g., neomycin/polymyxin B/dexamethasone ointment b.i.d. for 1-2 weeks)
Doxycycline 20-50 mg orally daily to b.i.d. (low-dose, for its anti-inflammatory effect) - indicated for multiple/recurrent chalazia or associated ocular rosacea

Step 3 - If no resolution after 3-4 weeks: Choose one

A. Intralesional steroid injection

Triamcinolone acetonide 40 mg/mL mixed 1:1 with 2% lidocaine with epinephrine (0.2-1.0 mL)
Alternatives: betamethasone or dexamethasone formulations
~80% success rate with one injection; can repeat 1-2 weeks later
Preferred for marginal lesions or lesions near the lacrimal punctum
Risks: skin depigmentation and fat atrophy (less common via conjunctival approach); rare retinal vascular occlusion from retrograde intra-arterial infiltration - discuss with patient before use

B. Incision and curettage (I&C) - surgical

Administer local anesthesia; evert the eyelid with a specialized chalazion clamp
Incise vertically through the tarsal plate
Curette the cyst contents; excise solid inflammatory material with fine scissors if needed
No suture required
Apply topical antibiotic 3x daily for 5 days post-procedure
All excised tissue (especially recurrent or atypical chalazia) should be sent for histopathology

Follow-Up

If medical therapy is used: review only if lesion persists beyond 3-4 weeks
After I&C: re-examine as needed
Recurrent chalazion at the same site = biopsy mandatory to rule out malignancy (sebaceous carcinoma)

Sources: Kanski's Clinical Ophthalmology 10th ed. | Wills Eye Manual | Goldman-Cecil Medicine | Textbook of Family Medicine 9e

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