nonym: meibomian cyst, tarsal cyst
A chalazion, or meibomian cyst, is a focus of granulomatous inflammation in the eyelid arising from a blocked meibomian gland (or tarsal gland).
Meibomian glands are modified sebaceous glands located in the tarsal plates of the upper and lower lids. (The tarsal plates are the two relatively tough elongated pieces of fibrous connective tissue which form the infrastructure of the eyelid.)
There are about 20-25 meibomian glands in each lid, arranged in vertical rows which drain at the lid margin. Their function is to secrete meibum, lipid component of the tear film. Meibum is a complex mixture of lipids which differs significantly from sebum. Without it the tear film would evaporate and run off too quickly to protect the eye adequately.
A chalazion is caused by non-infectious drainage occlusion of the gland, causing extravasation of meibum into the eyelid soft tissues. This is followed by a focal secondary inflammatory reaction. Disorders which cause abnormally thick meibum predispose to chalazia, which can therefore be multiple or recurrent.
Chalazion is non-infectious, in contrast to internal and external hordeolum. A hordeolum is an acute (usually staphylococcal) infection of the eyelid. There are two types, both of which are (confusingly) known as styes; however, they differ:
- Internal hordeolum - when the meibomian gland is infected, resulting in an abscess. This occurs only rarely.
- External hordeolum (an acute infection of the lash follicle ± its associated sebaceous gland of Zeiss or Moll). The term 'stye' is often used more specifically to refer to external hordeolum.
For other eyelid problems, see separate External Eye Overview - Lashes, Eyelids and Lacrimal System article.
- Chalazia are the most common of all lid lumps.
- They can occur at any age.
- Risk factors include:
- Chronic blepharitis
- Seborrhoeic dermatitis
- Diabetes mellitus
- Immune deficiencies
- Viral infections
- Chalazion presents as a gradually enlarging roundish, firm lesion in either the upper (more common) or the lower lid, usually 2-8 mm in diameter. There may be variability of size from day to day.
- 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. They can be bilateral. Multiple lesions may look more like a diffuse swelling of the lid.
- Everting the lid reveals 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.
- Occasionally, a chalazion of the upper lid can press on the cornea, so inducing astigmatism and causing blurred vision.
- A chalazion usually drains through the inner surface of the eyelid or is absorbed spontaneously over 2-8 weeks. A large chalazion may indent the cornea, resulting in slightly blurred vision.
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 is clinical. Distinguishing chalazion from internal and external hordeolum can be difficult.
During the first couple of days the three may be clinically indistinguishable: both conditions initially cause eyelid hyperemia and oedema, swelling and pain: swelling is initially diffuse and can occasionally be dramatic, closing the eye completely.
- Chalazion and external hordeolum are common conditions; internal hordeolum is rare.
- A chalazion is embedded in the tarsal plate; the overlying skin is freely mobile in the absence of infection. It is not tender to touch, unlike a hordeolum.
- Over 1-2 days, chalazion becomes a small non-tender nodule in the eyelid centre, whereas external hordeolum remains painful and localises to an eyelid margin.
- Chalazion typically causes yellowish swelling visible on the underside of the eyelid. In external hordeolum, a small yellowish pustule develops at the base of an eyelash, surrounded by hyperemia, induration, and diffuse oedema.
- Symptoms of an internal hordeolum are the same as for a chalazion but with more pain, redness and oedema. Inflammation may be severe, sometimes with fever or chills. Spontaneous rupture occasionally occurs, on the conjunctival side.
- Internal hordeolum.
- External hordeolum.
- Orbital or preseptal cellulitis.
- Early herpes zoster.
- Herpes simplex.
- Chalazion or hordeolum near the inner canthus of the lower eyelid must be differentiated from dacryocystitis and canaliculitis. Location of maximum induration and tenderness is the eyelid for a chalazion, near the side of the nose for dacryocystitis and over the punctum for canaliculitis.
Chronic chalazia that do not respond to treatment require biopsy to exclude tumor of the eyelid.
- Sebaceous gland carcinoma may masquerade as recurrent chalazion.
- Basal cell carcinoma.
- Squamous cell carcinoma.
- Merkel's cell tumour (rare).
- Lacrimal sac neoplasia (consider this in swellings above the medial canthus).
Recurrent or atypical chalazia need histology.
Chalazia can resolve spontaneously. The process may be helped by improving the flow of meibomian gland secretions:
- Twice-daily (minimum) warm compresses to warm up and loosen secretions. Try cotton pads soaked in warm water, applied for about 10 minutes.
- 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.
- If there is associated blepharitis, finish off by cleaning the lid margin, running the buds along the lid margin, cleaning the orifices. Suggest cotton buds dipped in 9:1 water:baby shampoo solution.
Explain to patients that resolution often takes time and that several weeks of regular hot lid bathing may be required.
Some lesions get progressively larger and simple lid hygiene techniques don't help. Consider referring individuals with troublesome lesions to the Eye Unit, where interventions include:
- A minor operation, usually under local anaesthetic. The lid is everted and clamped 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. The lid may remain swollen and bruised for about a week afterwards.
- Chalazion may occasionally be managed with a triamcinolone injection alone. This is reserved for softer, smaller lesions and is sometimes the preferred option in children. Multiple chalazia can be treated at the same time. The lesion regresses about 1-2 weeks after injection. This treatment is contra-indicated where there is co-existing infection. The success rate is about 75%.
- Large or multiple lesions may be treated with both curetting and steroid injection to the base of the curetted area.
- Persistent chalazia (particularly those associated with acne rosacea or seborrhoeic dermatitis) may benefit from a course of systemic antibiotics (eg, doxycycline 50 mg od for three months or lymecycline 408 mg od for at least three months).
Lesions that recur at the same site should be biopsied for histology.
There is scant research into the optimum management of an internal hordeolum. Common practice is to treat the acute infection first. Curetting then follows when necessary. Consider a week's course of chloramphenicol ointment (qds) or fucithalmic ointment (bd). Some advocate oral antibiotics for an internal hordeolum.
If there is associated cellulitis (preseptal or orbital), the patient will need oral antibiotics (eg, flucloxacillin 500 mg qds for one week and metronidazole 400 mg tds for one week) and ophthalmic supervision.
Referrals should be in line with local protocol. Consider a routine referral to the Eye Unit if:
- The chalazion is causing visual or other problems (eg, 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.
- You are considering a prophylactic course of antibiotics.
- The patient requests 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 looks unusual or is recurrent - particularly in older individuals, when sebaceous carcinoma is a significant differential diagnosis.
A low referral threshold is needed in young children, particularly with large chalazia (there is a risk of amblyopia) or where there is an associated infection.
Serious complications are rare. Large chalazia can induce astigmatism by pressing on the cornea (see 'Presentation', above) or cause a mechanical ptosis. An internal hordeolum may be associated with preseptal cellulitis. Complications of operative removal are rare but may include:
- (Rarely) canalicular trauma and globe perforation.
Complications of steroid injection include:
- Depigmentation at the injection site.
- Temporary skin atrophy.
- Subcutaneous white deposits.
- (Rarely) rise in intraocular pressure.
The most common problem is recurrence of the chalazion.
In predisposed individuals (see 'Associated diseases', above), regular lid hygiene may have a prophylactic role, although there is little evidence supporting this.
Further reading and references
Arbabi EM, Kelly RJ, Carrim ZI; Chalazion. BMJ. 2010 Aug 10341:c4044. doi: 10.1136/bmj.c4044.
Butovich IA; The Meibomian puzzle: combining pieces together. Prog Retin Eye Res. 2009 Nov28(6):483-98. doi: 10.1016/j.preteyeres.2009.07.002. Epub 2009 Aug 4.
Meibomian cyst (chalazion); NICE CKS, November 2015 (UK access only)
Oxford Handbook of Ophthalmology
Moorfields Manual of Ophthalmology
Biuk D, Matic S, Barac J, et al; Chalazion management--surgical treatment versus triamcinolon application. Coll Antropol. 2013 Apr37 Suppl 1:247-50.
Lindsley K, Nichols JJ, Dickersin K; Interventions for acute internal hordeolum. Cochrane Database Syst Rev. 2013 Apr 304:CD007742. doi: 10.1002/14651858.CD007742.pub3.
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