How do you treat a chalazion? What is a chalazion? What are the different presentations of a chalazion?

A comprehensive review of chalazions and chalazia with a depiction of the many different faces of chalazia

Dr. BCK Patel MD, FRCS

For family practice doctors, physicians, oculoplastic surgeons, ophthalmologists, residents and fellows

What is a chalazion?

A simple chalazion which presents as a “bump” on the eyelid and is usually painless and not tender The lesion may be soft or firm

A chalazion is initially a painless mass that develops on the eyelid. It is caused by a blockage of the Meibomian gland. The blocked gland allows the contents (lipogranulomatous material) to expand and will eventually allow the material to spread into the surrounding tissues, causing local inflammation.

Initially, the chalazia are soft or rubbery but go on to become firm. Inflammation or secondary infection will lead to tenderness of the lesions. Does an initial infection of the Meibomian gland cause a chalazion to develop or is it a blocked Meibomian gland that secondarily becomes inflamed and can become infected? The exact sequence is probably both of the above in different lesions.

A large chalazion with surrounding erythema will be tender to the touch and is best treated with incision and curettage

The relationship of the Meibomian gland in the upper eyelid to the orbicularis oculi muscle, eyelid margin and eyelashes is seen in the cross section image. The opening of the Meibomian glands is at the posterior part of the eyelid margin

Etymology of the word “Chalazion”

“Khalaza” is a Greek word meaning a “small knot”. The diminutive of “khalaza” is “khalazion”. Therefore the singular is “chalazion” and the plural is “chalazia” or “chalazions.

This is an acutely inflamed chalazion pointing outwards onto the skin with imminent perforation anteriorly. These are sometimes wrongly called “external hordeolum”, although the word hordeolum is best reserved for a stye which is an infection of the gland of Zeis and presents anteriorly at the root of a lash

An inflamed chalazion pointing anteriorly with surrounding erythema. These are also best treated with incision and curettage as they can become increasingly uncomfortable. It is fine to drain these anteriorly through the skin

Synonyms

Tarsal cyst, Meibomian cyst, External hordeolum (the word “hordeolum: is from the Latin “hordeolus” which stands for “barley” and was used because of the resemblance of the anterior chalazion to a grain of barley, Internal hordeolum

External hordeolum or chalazion presenting anteriorly. These are easily incized and drained anteriorly

An internal hordeolum or inward-pointing chalazion. The inflamed, infected Meibomian gland presents posteriorly where a yellow apex is seen. These tarsal-pointing lesions are easily drained via the conjunctiva with rapid resolution

Another internal hordeolum or posteriorly pointing chalazion with a pyogenic granuloma. These are best resected surgically and the underlying chalazion incized and drained

Increased risk of developing chalazia

Smoking
Blepharitis
Dry eye syndrome
Eyelid skin dermatitis
Acne rosacea
History of allergic skin conditions
Gastritis and irritable bowel syndrome (although the exact correlation is unknown)

Natural history of a chalazion

The initial inciting factor is blockage of a Meibomian gland. This causes the sebaceous material that is within the meibomian gland to expand. This results in a painless swelling, which is called a chalazion. Initially, the lesions are painless and expand slowly. Local tenderness occurs when there is spread of the sebaceous material to the surrounding tissues leading to local inflammation, or if there is a secondary infection which results in increased tenderness.

Untreated, chalazia can increase in size and become quite firm although most will burst through to the surface (skin) or through the conjunctiva and will resolve slowly but surely.

Chalazia may occur in childhood and in adults, often in the 30 – 50 age group. Predisposing factors include conditions like underlying blepharitis and acne rosacea. The use of makeup and the wearing of contact lenses does not increase the incidence of chalazia.

Recently, with Covid, it has become apparent that the wearing of masks may lead to a drying effect on the eyelid margins with secondary blockage of the Meibomian glands. We have seen a significant increase in the incidence of chalazia during the Covid years 2020-2023.

A large chalazion on the upper eyelid may cause a mechanical ptosis. The change in the curvature of the eyelid and also the pressure on the cornea can make it difficult to wear contact lenses.

Lower eyelid chalazia can result in an ectropion with resultant epiphora (tearing). Secondary calcification may develop in the presence of chronic chalazia. Malignant transformation is extremely rare.

A chronic chalazion which presents as a hard nodule of six-months’ duration. These will generally need a combination of incision and curettage and a steroid injection, together with warm soaks and topical antibiotics. the patient will have to be patient as final resolution can take weeks to months

External Hordeolum

Infections of the glands of Zeis are called styes or external hordeolum. These sebaceous oil glands open into the eyelash follicles. The term external hordeolum has erroneously been used for a chalazion that becomes infected and erodes through the skin.

A chalazion that is showing anteriorly through the skin with the appearance of a barley corn: it was therefore described as an external hordeolum. These lesions can be drained anteriorly. If they are firm, injection with steroids is reasonable. Even though they look dramatic, once they heal, the eyelid does not show any residual scarring

What are Meibomian Glands?

Meibomian glands ae glands within the tarsus of the upper and lower eyelids. There are 30 glands in the upper eyelid and about 25 glands in the lower eyelid. They are also called tarsal glands.

Meibomian glands within the upper and lower eylids. There are 30 such glands in the upper eyelid and 25 glands in the lower eyelid

Meibomian glands produce an oily substance called meibum which is important in reducing the evaporation rate of tears in our tear film. These are exocrine glands: 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, which causes them to release the oily substance into the Meibomian duct. Meibum not only reduces evaporation of the aqueous component of the tear film, but it 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 further assists in allowing the eyelids to shut in an airtight manner.

Cross section illustration of the eyelid margin showing the relationship of the Meibomian gland to the eyelashes and the glands of Zeis (which form styes) and Moll (which form cysts of Moll)

Meibomian Glands: Etymology

Heinrich Meibom (1638 – 1700) was a German physician who studied in France, Germany, Italy and England. He went on to become a Professor of Medicine and also a Professor of History and Poetry. He wrote Latin poetry for which he was well known.

Chronic chalazion (Meibomian gland cyst) without local signs of inflammation or infection. These present as firm nodular lesions and are best drained and injected with a steroid injection

Differential Diagnosis of a Chalazion

Stye
Adenocarcinoma
Sebaceous Gland Carcinoma
Nodular basal cell carcinoma
Schwannoma

This patient has a stye which is the lesion close to the eyelid margin and originates from the lash root and a chalazion which is the lower lesion. There is also a small inclusional cyst supero-medially on the upper eyelid and a seborrheic keratosis on the lateral nasal wall. There are also multiple small papillomas

Histopathology of Chalazia

Histopathology of the contents of a chalazion reveals a lipogranulomatous reaction with multinucleated giant cells, foamy macrophages, plasma cell, neutrophils and lymphocytes with lipid vacuoles.

Histopathology will show areas of clear spaces which do not stain with H&E staining because these are lipid droplets. Older lesions may manifest fibrosis

Giant cells, lymphocytes, lipid-laden cells

Histopathology courtesy of Prof. Nick Mamalis MD, MoranCore

How do you manage chalazia presenting acutely?

Anterior chalazion that is ready to burst through the skin. These are best treated conservatively with pressure, warm soaks and topical antibiotics. Most of these will resolve with conservative management and do not need surgical drainage. They also do not leave any scarring

Resolving anterior chalazion: note the wrinkling of the skin over the lesion. That is a sign that the lesion is resolving. Simple conservative treatment is indicated and warm soaks and pressure as if trying to “burst a pea”

External hordeolum with acute inflammation which is best treated with external drainage

Patients may present with a non-tender bump on the upper or lower eyelid, in which case the lesion may cause distortion of the cornea which affects vision or may be cosmetically unacceptable. Larger lesions can cause pressure on the cornea with resultant astigmatism. Central chalazia can be in the line of sight and can also cause a mechanical ptosis interfering with the field of vision.

Management:

Warm soaks ae applied to the lesion four to five times a day
Topical antibiotic ointment or an antibiotic-steroid ointment is prescribed to be used three times a day to the lesion
Heat may be applied to the lesions with heated rice-pods or even a microwaved potato!
The important thing to remember is to apply pressure on the enlarged Meibomian gland: this pressure allows the contents to become softer and allows egress of the material from the Meibomian gland.
Systemic antibiotics are usually not indicated for simple chalazia. These may be prescribed if there is local spread of inflammation into the eyelid with resulting preseptal cellulitis
If the gland is inflamed, it is best to incize and drain the lesion via the conjunctival approach. If a chalazion is already erupting through the skin of the eyelids, it is reasonable to make the opening on the cutaneous side. See our videos which demonstrate the technique of incizing and draining chalazia. After incizing and draining chalazia, the patient is asked to continue warm soaks and apply the prescribed ointment three times a day for a week

Example of a resolving chalazion: nothing needs to be done other than warm soaks. The wrinkles skin indicates the resolution of this condition

Anteriorly pointing chalazion in a child. These are ready to “pop” with pressure and warm soaks

A left eyelid chalazion which resolved with appropriate conservative management of heat and topical antibiotics. The photograph at the bottom was taken one month later, illustrating complete resolution of the chalazion

Management of Chronic Chalazia

A chronic chalazion without local tenderness, inflammation or infection. These present as firm, non-tender nodular lesions which are best treated with incision and curettage and with steroid injection

A chronic chalazion that has erupted through the eyelid skin with drying of the surface and crusting. This will respond to conservative management with warm soaks and topical ointment

After a few weeks, chalazia can become firm and even nodular. If left untreated, these chalazia can take weeks to months to slowly resolve. As the mass effect is often a nuisance in the presence of chronic chalazia, we usually carry out incision and drainage of the lesions with local anesthetic injection and inject the firm remnant of the chalazion with dexamethasone 4% solution.

Whenever draining chalazia, the following points must be followed:

Drainage is with vertical incisions on the conjunctival side of the tarsus unless the lesion is erupting through the skin of the eyelid
Only make vertical incisions and not horizontal like some textbooks portray. And certainly do not create vertical and horizontal incisions and excize parts of the tarsus as some ophthalmic books illustrate. There is no reason to sacrifice the tarsal plate unless a biopsy is being obtained (see below)
Beware of involvement of surrounding Meibomian glands. It is not uncommon to find other glands adjacent to the inflamed or blocked Meibomian gland to also be affected. They will also need draining. We frequently apply the two-finger pressure technique to chalazia that we drain to ensure that we also drain any surrounding inspissated glands

Chronic chalazion of the left lower eyelid which has been present for more than six months. Presents as a non-tender but firm mass. These are best treated with incision and curettage and injection of steroids. The thickened lining will take some weeks to improve

Chronic Meibomianitis

Patients with acne rosacea and chronic blepharitis can present with chronic meibomianitis with multiple glands being inflamed and varying number of chalazia. These patients will often present with recurring chalazia and will require topical tetracycline as well as management of the underlying condition. There may be a reduction of eyelashes even in the absence of malignancy. Treatment with intense pulsed light has been shown to improve acne rosacea and also inflammation of the eyelids.

Chronic Meibomianitis affecting multiple glands with associated chalazia. These patients often need systemic antibiotics as well as a lid routine of warm soaks

Beware Chronic Chalazia in Older Patients or Recurring Chalazia

Chronic chalazia in older patients or recurrent multiple chalazia should alert the physician to perform a biopsy as sebaceous gland carcinomas can mimic chalazia. If the chalazion has a smooth yellow surface without discomfort, it is best to biopsy the lesion. Also look for any associated loss of eyelashes. Specimens should be submitted fresh to the ophthalmic pathologist for appropriate staining looking for evidence of sebaceous gland carcinoma

Firm chronic chalazion of the left lower eyelid with no loss of eyelashes. Incsion, curettage and steroid injections indicated

Chronic Chalazia with Pyogenic Granulomas

Anteriorly there appears to be no mass but eversion of the eyelid shows a posterior pyogenic granuloma. These chalazia erode through the tarsal conjunctiva causing local inflammation. Because of the granulomatous inflammation, a pyogenic granuloma may form as seen here. These need to be resected and an incision and curettage needs to be performed together with injection of steroids

Chronic inflammation that bursts through the conjunctival surface can sometimes present with a pendulous inflammatory mass which is a pyogenic granuloma. These are removed surgically and the base scraped with a chalazion scoop and a steroid injection is administered

A sesile conjunctival granuloma in the presence of an underlying chalazion. These are pyogenic granulomas which need to be resected and the underlying chalazion needs to be incized and drained. Steroid injections are carried out at the same time

Chalazia with Secondary Cellulitis

A chalazion with early cellulitis. These lesions can be acutely tender and may need oral antibiotics as well as incision and curettage

Multiple chalazia, especially in children, can spread inflammation and secondary infection into the surrounding skin resulting in a preseptal cellulitis. Indeed, whenever preseptal cellulitis is seen in children, always palpate the eyelids to exclude the presence of inflamed chalazia. Once the underlying chalazia are properly treated, the cellulitis will resolve.

When children present with anterior cellulitis, underlying chalazia should be suspected. CT scan of this child shows several chalazia with no postseptal changes. Once the chalazia are treated, the preseptal cellulitis resolves

Acute chalazion with spread of inflammation and infection into the surrounding subcutaneous tissues with early preseptal cellulitis. These patients will need incision and curettage together with topical antibiotics and sometimes oral antibiotics

Multiple Chalazia

Multiple chalazia are seen in patients with chronic Meibomian gland disease, acne rosacea and chronic blepharitis. Multiple chalazia may also present in multiple eyelids and are thought to be hormonally related in females.

Multiple chalazia affecting all four eyelids. Diet has no bearing on the occurrence of chalazia

Multiple chalazia which are eroding anteriorly through the skin. These will often present as firm nodules. Note the yellow color of the sebaceous material. When performing incision and curettage, it is important to assess the surrounding Meibomian glands as well since they may also be involved

It is important to evert the eyelid and look across the whole width of the tarsal surface as multiple chalazia may be present as illustrated here

When should steroids be injected into chalazia?

50% of early soft chalazia will resolve just with an intralesional injection of a steroid like dexamethsone. When the lesion or lesions are firm and multiple, it is best to administer local anesthetic, perform an incision and curettage and then inject with a steroid.

Indications for Incision and Curettage

Medial upper eyelid chalazion: the chalazion can be defined by applying gentle pressure with a Q-tip, thereby making incision easier when draining these

Typical posterior chalazion which lends itself nicely to incision and curettage. The incisions must be vertical and not horizontal

Early soft chalazia can be incized and drained when the patient wants a quick resolution
Chronically inflamed and tender chalazia should be incized and drained
Recurrent chalazia should be incized and drained and biopsied if indicated
Multiple chalazia are best injected with local anesthetic, drained and injected with steroids

How do you perform an incision and curettage of a chalazion?

Internal hordeolum type of chlazion which can develop a granulomatous mass which can go on to develop a pyogenic granuloma. These are best treated with incision and curettage and steroid injections

Instruments

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
Gauze
Eye patches
Westcott scissors and 0.5 mm forceps may be needed
Pathology specimen pot may rarely be needed

Surgical Steps:

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
Patients (usually men) will sometimes feel faint at the end of the procedure. It is best to leave the head reclined until the patient is feeling well enough to stand

Chronic chalazion close to the upper punctum of the left upper eyelid. When incizing these, it is important to protect the punctum and canaliculus, often with the help of a Bowman probe

External hordeolum of the left lower eyelid resembling a corn of barley. These are best drained anteriorly. When the acute process involves the area at the root of the lash, they are termed styes.

Chronic Chalazia

Chronic chalazia are chalazia that have been present for many weeks to months and are usually firm and painless. These are best treated with local anesthetic injection, incision and curettage, together with dexamethasone injection. We apply our two-finger firm pressure technique to break down any surrounding areas which may have chronic material in them. The patient should be warned that the bulk of the lesion will reduce in size over the subsequent few days but the final resolution can often take many weeks. Patience is key here…..

Chronic chalazion with ulceration anteriorly and secondary calcification. In such cases, it is important to send samples looking for underlying malignancy

Giant Chalazion

These are large chronic chalazia and will often look like they are occupying the whole eyelid. They will frequently emanate from multiple Meibomian glands so it is important to drain all of them properly

Giant chalazion of the left lower eyelid: these will often start as a single chalazion. With surrounding inflammation, other Meibomian glands may become involved and result in a “giant chalazion”. When draining these, it is important to identify and drain all the surrounding glands that may be involved

Chalazia in Children

A large chalazion in a child. When incizing and draining these, it is always wise to look for other chalazia on the same and other eyelids as children will often have multiple chalazia

Multiple chalazia in eyelids. Children will often get multiple chalazia in the same eyelid and multiple eyelid. No cause has been identified. When chronic, incision and curettage is reasonable. We evert all four eyelids to ensure all the Meibomian glands have been squeezed as there will frequently be low-grade insipissation in some glands. It is important to explain to the parents that other glands can become blocked days or weeks after any drainage has been performed. Recent studies show that Azithromycin may be beneficial for some cases

Children will often present with chalazia, often multiple and frequently recurrent. There is no known cause of this and most will settle with conservative management discussed above. Parents can get frustrated by the recurrent chalazia that some children get. We always reassure them that they eventually resolve and do not leave any underlying scarring of the eyelids. In some cases oral antibiotics like Azithromycin are indicated

Children will often be brought in with small “bumps” on the eyelid where the family will complain that the chalazia “have not gone away”. Chronic chalazia can take weeks to month to resolve. Topical steroids may be needed but mostly it is a case of allowing the body to continue its healing process. Haraka haraka haina baraka

Chalazion in patients with skin of color

Chalazion in an African-American. Care must be taken not to inject steroids superficially because of the risk of hypopigmentation

Whereas the management of chalazia in patients who have skin of color is the same as in white Caucasians, care must be taken not to inject with steroids superficially as hypopigmentation may occur.

References

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