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MattiSeppänen

Hordeolum and Chalazion

A hordeolum develops when a sebaceous gland in the lid margin (gland of Zeis, leading to external hordeolum or stye) or in the tarsus (meibomian gland, leading to internal hordeolum) becomes acutely infected.
- The most common causative agent is Staphylococcus aureus.
A chalazion develops when a meibomian gland becomes obstructed and chronically inflamed. Secretions from the obstructed gland are released into the surrounding tissue, and a lipogranuloma develops. With the chalazion, granulation tissue may form a red wattle-like change, a so-called pyogenic granuloma, on the conjuctival side.
A large chalazion may apply pressure on the cornea and temporarily impair vision as it temporarily causes astigmatism.
In older age, sebaceous gland adenocarcinoma and Merkel cell carcinoma of the eyelid may resemble a chalazion.

Hordeolum and chalazion are common, occurring primarily in children and young adults. They may recur at another site either in the same or in the neighbouring eyelid.
The dry eye syndrome, chronic blepharitis, seborrhoeic dermatitis and hormonal factors (the composition of sebum) are predisposing factors.
Refractory and recurrent chalazions can be caused by rosacea.

In the acute phase, the symptoms include swelling and pain of the eyelid as well as redness of the eyelid and conjunctiva.
In the chronic phase, there is a round lump on the eyelid.
External hordeolum develops within a couple of days, becoming a focus of infection at the eyelid margin and containing yellowish pus.
Especially an internal hordeolum very often develops to a non-tender solid subcutaneous nodule (chalazion) that is most often located in the upper eyelid.
Sometimes there are several chalazions either in the same eyelid or bilaterally.

Dacryoadenitis
- Tenderness on palpation is located at the upper lateral margin of the orbit.
Dacryocystitis
- Tenderness on palpation is located at the lower medial corner of the eye.
Palpebral tumours
- Sebaceous gland carcinoma
If a chalazion appears after middle age, recurs at the same site or is otherwise atypical, consider the possibility of a carcinoma.
- When suspecting a malignant change, a biopsy specimen should be taken. If the change is near the palpebral margin or lacrimal canaliculus, a referral to an ophthalmologist for the biopsy is warranted.

A hordeolum will usually resolve spontaneously in 1-2 weeks. A warm compress and cleaning the eyelid margin can speed up the healing process.
If necessary, local antimicrobial therapy may be considered in a prolonged situation:chloramphenicol ointment or, prescribed by an ophthalmologist, dexamethasone-chloramphenicol ointment for 1-2 weeks.
Treatment of a chalazion consists of heat treatment with warm compress: for 15 min a warm compress on closed eyelids twice a day for a week. After using the warm compress, the eyelid should be massaged with clean fingers or a cotton swab which has a wooden handle.
If the symptoms recur or there is rosacea, doxycycline 100 mg once daily orally even for 2-3 months may be considered.
In a refractory chalazion, symptoms may be associated with a wider infection of the skin area, and a careful examination (by a general practitioner, dermatologist or ophthalmologist) is needed. The condition may require oral antimicrobial treatment.
Often, a chalazion gradually disappears spontaneously. It may, however, initially enlarge and may remain similar even for months.

A large chalazion that interferes with the function of the eyelid still 3 months after the development of the chalazion.
A chalazion that has recurred at the same spot on the eyelid or is otherwise atypical
Suspicion of a malignant change

Indications	Should be considered, if the symptom gets prolonged. In practice, it should first be seen if in over 3 months the chalazion gets better.
Preparation	Anaesthesia with lidocaine + adrenaline Tarsus should be anaesthetised as well.
Course of the procedure	Chalazion forceps should be used; the side with the hole is placed against the eye. Tarsus is everted. Vertical incision is done with a knife after which the gland is emptied with a scoop. The forceps is removed in the end.
Aftercare	Plenty of chloramphenicol ointment should be applied on the eye, and folded dressings are used as protection. The patient may have a seat and apply pressure on the eyelid with his/her palm for 15 min. Chloramphenicol ointment 3 times daily for 3-7 days to be carried home
Note	If the change is recurrent or atypical, a sample for histopathological diagnosis, including some tarsus tissue, is taken. In differential diagnosis, sebaceous gland carcinoma is to be considered. A request to exclude sebaceous gland carcinoma should be included in the referral form for histopathological diagnosis.

Source: Leivo T. [Hordeolum and chalazion]. In: [Handbook of ophthalmology]. Duodecim Publishing Company Ltd 2022.