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MattiSeppänen

Hordeolum and Chalazion

Essentials

  • 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 http://www.dynamed.com/condition/chalazion#COMPLICATIONS.
  • At an advanced age, sebaceous gland adenocarcinoma and Merkel cell carcinoma of the eyelid may resemble a chalazion.

Epidemiology

  • 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.

Symptoms and findings

  • 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.

Differential diagnosis

  • 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 considered. If the change is near the palpebral margin or lacrimal canaliculus, a referral to an ophthalmologist for the biopsy is warranted.

Treatment

  • Initial treatment of a hordeolum consists of chloramphenicol ointment or, on ophthalmologist's orders, 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 or if the symptoms suggest the initial phase of preseptal cellulitis, the medication consists of cephalosporin 500 mg 3 times daily orally for 1-2 weeks.
  • A chalazion always gradually disappears spontaneously. It may, however, initially enlarge and may remain similar even for months.
  • Surgical treatment of a chalazion: see table T1.

Criteria for referral

  • 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

Surgical treatment of a chalazion.

IndicationsShould be considered, if the symptom gets prolonged. In practice, it should first be seen if in over 3 months the chalazion gets better.
PreparationAnaesthesia with lidocaine + adrenaline
Tarsus should be anaesthetised as well.
Course of the procedureChalazion 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.
AftercarePlenty 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
NoteIf 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. Näärännäppy ja luomirakkula [Hordeolum and chalazion]. In: Silmätautien käsikirja [Handbook of eye diseases]. Duodecim Publishing Company Ltd 2020.