Synonym: meibomian cyst

Description

Meibomian glands (sometimes referred to as tarsal glands) are modified sebaceous glands located in the tarsal plates of the upper and lower lids. There are about 20-25 of them in each lid, arranged in vertical rows with their orifices opening out on to the lid margin. Their function is to secrete the lipid component of the tear film, without which the tear film would be unstable and break up too quickly.

A chalazion is a chronic, sterile lipogranulomatous lesion formed within the meibomian gland. It occurs when the orifice blocks off and may be associated with the rupture of the gland. It is an inflammatory reaction to retained sebaceous secretions.¹ This may be a multiple or recurrent problem which may occur spontaneously or secondary to meibomian gland dysfunction.

Epidemiology

• Chalazia are the most common of all lid lumps.²
• They can occur at any age.
• Risk factors include:
  • Chronic blepharitis
  • Rosacea
  • Seborrhoeic dermatitis
  • Pregnancy
  • Diabetes mellitus
  Rare associations include:
  • Hyperlipidaemia
  • Leishmaniasis
  • Tuberculosis
  • Immune deficiencies
  • Viral infections

Presentation

Chalazion

• It presents as a gradually enlarging roundish, firm lesion in either the upper (more common) or lower lid, usually 2-8 mm in diameter. There may be variability of size from day to day.³ It may be a little tender initially as the inflammatory reaction occurs but this settles rapidly and, ultimately, it is painless.
• There may be multiple lesions and they can be bilateral. Multiple lesions may look more like a diffuse swelling of the lid.
• Evert the lid and look for a discrete, immobile, round, yellowish lump. If the chalazion has grown through the tarsal plate and tarsal conjunctiva, a polypoidal granuloma may form, seen on eversion of the lid. There should be no associated ulceration, bleeding, telangiectasia, tenderness, or discharge.¹
• Occasionally, a chalazion of the upper lid can press on the cornea, so inducing astigmatism and causing blurred vision.

Internal hordeolum

This is a tender swelling within the tarsal plate, which progressively enlarges and which may eventually discharge anteriorly (through the skin) or posteriorly (through the conjunctiva).

Diagnosis

Diagnosis is clinical. However, it is not always easy to differentiate between a chalazion and hordeola. A chalazion is embedded in the tarsal plate; the overlying skin is freely mobile in the absence of infection. The key thing is that it is not tender to touch, unlike hordeola. It can be more tricky to differentiate between an internal hordeolum (infected meibomian cyst) and an external hordeolum or stye (infected lash follicle ± its associated glands). Don't worry too much: once you have identified that an infective process is taking place (redness, tenderness, pain ± evidence of pus contained within), the management is the same (see 'Management, internal hordeolum' below).

Differential diagnosis

Infections

• Internal hordeolum
• External hordeolum
• Preseptal cellulitis
• Orbital cellulitis
• Early herpes zoster
• Herpes simplex

Tumours¹

• Sebaceous gland carcinoma is notorious in masquerading as recurrent chalazion or unilateral blepharoconjunctivitis.
• Basal cell carcinoma.
• Squamous cell carcinoma.
• Melanoma.
• Merkel's cell tumour (rare).
• Lacrimal sac neoplasia (think of this in swellings above the medial canthus).

Investigations

Recurrent or atypical-looking chalazia need histology.

Associated diseases⁴

• Blepharitis
• Acne rosacea
• Seborrhoeic dermatitis

Management

Chalazion

Chalazia can spontaneously resolve. The process may be helped by improving the flow of meibomian gland secretions:

1. Twice daily (minimum) warm compresses to warm up and loosen secretions. Try make-up cotton pads soaked in warm water and applied for about 10 minutes.³
2. Massage the lids, 'milking' the secretions out (downward movement on the upper lid and upward movement on the lower lid). Do this with clean fingers or cotton buds.¹
3. If there is associated blepharitis, finish off by cleaning the lid margin, taking care to run the buds along the lid margin only, cleaning the orifices, and not on the globe itself. Suggest cotton buds dipped in 9:1 water:baby shampoo solution.

It is important to explain to patients that resolution often takes time and that several weeks of regular hot bathing may be required.³ A small asymptomatic cyst can be safely left alone.¹ A simple chalazion does not need treatment with antibiotics,^1,3 even if it is very large.

Some lesions get progressively larger and simple lid hygiene techniques don't help. Consider referring individuals with troublesome lesions to the eye clinic, where interventions include:

• A minor operation under local anaesthetic. The lid is everted using a special clamp and the cyst is incised. The contents are curetted through the tarsal plate. A short course of ocular chloramphenicol (qds for a week) is prescribed. Follow-up is not usually needed. Note that the lid may remain swollen and bruised for about a week after the procedure.
• Occasionally, a chalazion is managed with a triamcinolone injection. This is reserved for softer, smaller lesions and is sometimes the preferred management option in children. Multiple chalazia can be treated in one go. The lesion regresses about 1-2 weeks after injection. This treatment is contra-indicated where there is co-existing infection.¹ The success rate is about 75%.
• Large or multiple lesions may be treated with a combination of surgery and steroid injection.
• Persistent chalazia (particularly those associated with acne rosacea or seborrhoeic dermatitis) may benefit from a course of systemic antibiotics (e.g. doxycycline 50 mg od for three months⁴ or lymecycline 408 mg od for at least three months³).

Internal hordeolum

There is surprisingly scant research into the optimum management of an internal hordeolum.⁵ Common practice is to treat the acute infection first prior to curetting out the chalazion if this is subsequently considered necessary (incising into infected tissue may result in spreading of the infection). Consider a week's course of chloramphenicol ointment (qds) or fucithalmic ointment (bd). Some advocate oral antibiotics for an internal hordeolum³ but practice does vary. If there is associated cellulitis (preseptal or orbital), the patient will definitely need oral antibiotics (e.g. flucloxacillin 500 mg qds for 1 week and metronidazole 400 mg tds for 1 week) and ophthalmic supervision.²

Referring

Consider a routine referral to the Eye Unit if:¹

• The chalazion has grown so large it is causing visual or other problems (e.g. cosmesis, foreign body sensation).
• The chalazion is persistent (see local criteria: some suggest after 4-5 weeks; others may wait until >6 months) and not responding to conservative treatment.
• If you are considering a prophylactic course of antibiotics.
• The person is wanting a rapid resolution of the chalazion.

Think of an urgent referral to the Eye Unit if:

• There is associated preseptal cellulitis (rarely: orbital cellulitis).
• The chalazion is unusual looking or recurrent¹ - particularly in older individuals: could this be a sebaceous carcinoma?

Have a low referral threshold in young children,³ particularly those with large chalazia (as there is a risk of amblyopia) and where there is an associated infection.

Complications

Serious complications are rare. Large chalazia can induce astigmatism by pressing on the cornea (see 'Presentation' above) or cause a mechanical ptosis.³ An internal hordeolum may be associated with preseptal cellulitis. Complications of operative removal are rare but may include:

• Haemorrhage.
• Infection.
• (More rarely) canalicular trauma and globe perforation.

Perhaps the most common problem is recurrence of the chalazion. Complications of steroid injection include:¹

• Depigmentation at the injection site.
• Temporary skin atrophy.
• Subcutaneous white deposits.
• (Rarely) rise in intra-ocular pressure.

Prognosis

Up to 50% of chalazia resolve (spontaneously or with conservative treatment)¹ but it is not uncommon for them to recur.⁵

Prevention

In predisposed individuals (see 'Associated diseases' above), regular lid hygiene may have some sort of prophylactic role³ but the evidence surrounding this is a little scanty.

Document references

1. Meibomian cyst, Clinical Knowledge Summaries (May 2010)
2. Denniston AKO, Murray PI. Oxford Handbook of Ophthalmology (OUP), 2008
3. Arbabi EM, Kelly RJ, Carrim ZI; Chalazion. BMJ. 2010 Aug 10;341:c4044. doi: 10.1136/bmj.c4044.
4. Jackson TL. Moorfields Manual of Ophthalmology, Mosby (2008)
5. Lindsley K, Nichols JJ, Dickersin K; Interventions for acute internal hordeolum. Cochrane Database Syst Rev. 2010 Sep 8;(9):CD007742. [abstract]

Acknowledgements