Ophthalmology - Eyelid disorders
Chalazion | Clinique Omicron Québec
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Chalazion is a chronic inflammatory granulomatous cyst of the eyelid, resulting from obstruction and retention of the lipid content of a Meibomius gland - one of the specialized sebaceous glands aligned in the palpebral tarsus. Unlike styes, with which it is frequently confused by patients, chalazion is an aseptic lesion: it is not a bacterial infection, but a granulomatous foreign-body inflammatory reaction triggered by the release of glandular lipids into the surrounding palpebral tissue, following obstruction of the gland's excretory duct. Clinically, it appears as a firm, rounded, painless or only slightly painful nodule, located in the thickness of the eyelid - most often the upper eyelid - mobile under the skin, without adherence to the cutaneous plane and without significant redness in the chronic phase. Chalazion is one of the most common palpebral disorders, affecting all age groups but peaking in adults between the ages of 30 and 50, and occurring more frequently in people with chronic blepharitis, acne rosacea or seborrheic dermatitis, conditions that favor hypersecretion and thickening of palpebral sebum. In the majority of cases, chalazion is a benign condition that resolves spontaneously in a few weeks to months with appropriate local care; persistent or recurrent cases may require intralesional corticosteroid injection or surgical incision-curettage. Particular attention should be paid to recurrent chalazions at the same site in patients over 40 years of age, for whom a biopsy is recommended to exclude sebaceous carcinoma of the eyelid, a rare tumor that can mimic a benign chalazion.
Meibomian gland anatomy and formation mechanism
Understanding the structure and function of the Meibomian glands is essential to understanding why chalazion forms and how to prevent it:
- Meibomian glands are modified sebaceous glands, organized in vertical rows in the tarsus - the rigid cartilaginous plate that gives each eyelid its shape; there are about 25 to 40 of them in the upper lid and 20 to 30 in the lower, with their excretory orifices opening in a line on the free palpebral edge, just behind the row of eyelashes.
- They secrete a complex lipid mixture (meibum) that forms the outer lipid layer of the tear film, the most superficial layer of the protective film covering the cornea; this lipid layer slows tear film evaporation and prevents dry eye syndrome.
- When the excretory orifice of a Meibomius gland becomes blocked - through thickening of the meibum, hyperkeratinization of the excretory duct or local inflammation - sebum accumulates in the body of the gland and eventually ruptures the gland wall, releasing lipids into the surrounding tarsal stroma.
- Macrophages and other local immune cells phagocytose these extracellular lipids but are unable to digest them completely; a foreign-body granulomatous reaction of the lipogranuloma type forms, progressively encapsulated by fibrous tissue, constituting the palpable nodule characteristic of chalazion.
- Unlike internal stye (hordeolum internus), which is an acute suppurative infection of a Meibomian gland by Staphylococcus aureus, true chalazion is a sterile, chronic inflammatory process; the two entities may occur one after the other, and an untreated stye may evolve into a residual chalazion.
Risk factors and predisposing conditions
Certain medical conditions and lifestyle habits increase the risk of developing chalazions, which often recur:
| Risk factor | Favoring mechanism |
|---|---|
| Chronic blepharitis | Chronic inflammation of the palpebral free edge, most often of staphylococcal origin or associated with dysfunction of the Meibomian glands (DGM); promotes obstruction of excretory orifices by scale deposits and bacterial biofilms; most frequent cause of recurrent chalazions. |
| Acne rosacea | Chronic skin condition affecting the face and frequently associated with dysfunction of the Meibomian glands; the meibum is thicker and more viscous, more easily obstructing the excretory ducts; recurrent chalazions are a classic ophthalmological manifestation of rosacea. |
| Seborrheic dermatitis | Sebaceous hypersecretion of cutaneous and palpebral glands, leading to obstruction of the Meibomian glands; often associated with scaly blepharitis |
| Severe dry eye syndrome | Instability of the tear film due to lipid deficiency (Meibomius gland dysfunction) maintains a vicious circle of palpebral inflammation and glandular obstruction. |
| Wearing contact lenses | Contact lenses, especially when worn for long periods, disrupt tear film dynamics and can lead to chronic palpebral inflammation and meibomian gland dysfunction. |
| Eye make-up | The application of make-up to the free edge of the eyelid (inner eyeliner, mascara) can obstruct the orifices of the Meibomius glands and promote their dysfunction, particularly when make-up removal is incomplete. |
| Immunodepression | Immunocompromised patients (HIV, immunosuppressive treatments) have an increased risk of multiple and recurrent chalazions, sometimes of large size, linked to an altered local inflammatory response. |
| Hypothyroidism | Changes in lipid metabolism associated with hypothyroidism may alter meibum composition and promote glandular obstructions; clinical association documented in several series of recurrent chalazions |
Symptoms and clinical presentation
Chalazion presents a characteristic clinical course in two phases, an initial inflammatory phase and a chronic cystic phase, with distinct manifestations:
- Initial phase (internal stye or acute chalazion): appearance of redness, diffuse swelling of the eyelid and pain or tenderness on palpation of the palpebral margin; this phase generally lasts 1 to 3 days and may be difficult to distinguish clinically from an incipient infectious stye.
- Chronic phase (constituted chalazion): progressive appearance of a firm, well-defined, rounded or oval nodule, located in the thickness of the eyelid; redness and pain fade; the nodule is mobile under the skin, non-adherent to the skin surface, and usually measures 2 to 8 mm in diameter.
- Preferential location in the upper eyelid (about 60 to 70 % of cases) due to the greater number of Meibomian glands; may involve the lower eyelid; multiple simultaneous or bilateral chalazions are possible, particularly in cases of underlying chronic blepharitis.
- Viewed from the inner (conjunctival) surface of the eyelid, the chalazion appears as a raised yellowish or greyish area through the thin, translucent tarsal conjunctiva, reflecting the lipid content of the granuloma.
- Visual discomfort due to corneal compression may occur if the chalazion is large (transient astigmatism induced by mechanical deformation of the cornea); slightly blurred or distorted vision in the affected eye, which normalizes after resolution of the chalazion
- Mechanical Ptosis (drooping of the upper eyelid) possible with large chalazions compressing the levator muscle of the upper eyelid
- Spontaneous evolution varies: complete spontaneous resolution without treatment in about 25 to 50 % of cases in 2 to 6 months; residual cyst persisting for months to years in other cases; spontaneous fistulization through the conjunctiva or skin with evacuation of the lipid content in a minority of cases.
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Chalazion and hordeolum are two distinct palpebral conditions that are often confused. External hordeolum is an acute infection of an eyelash hair follicle or Zeis gland by Staphylococcus aureus, Internal stye is a painful boil at the free edge of the eyelid, with a pustule visible at the base of the lash. Internal stye is a suppurative infection of a meibomian gland, more painful and deeper. Chalazion is a chronic lesion, painless in its constitutive phase, with no infectious aspect. The distinction is clinically important, as treatment differs: stye may require local or oral antibiotic therapy, while antibiotics are of no use in aseptic chalazion.
Differential diagnosis
Several palpebral affections can mimic a chalazion and must be distinguished, in particular to avoid ignoring a malignant tumor:
| Affection | Distinguishing features |
|---|---|
| Stye (external or internal hordeolum) | Intense pain, diffuse redness of the eyelid, local heat, visible pustule in the case of external stye; acute evolution within a few days; response to warm compresses and local antibiotics. |
| Sebaceous carcinoma of the eyelid | Rare but serious malignant tumor, developed from cells of the Meibomius or Zeis glands; mimics a recurrent chalazion at the same site, sometimes with localized loss of eyelashes (madarosis), an atypical appearance or diffuse infiltration of the tarsus; biopsy essential for any recurrent chalazion in patients over 40 to 50 years of age or with an atypical appearance. |
| Palpebral squamous cell carcinoma or basal cell carcinoma | Ulcerated lesion with beaded or indurated margins, often on the lower eyelid, in fair-skinned elderly patients with chronic sun exposure; no cystic appearance; diagnostic biopsy |
| Inclusion squamous cell cyst | Superficial subcutaneous cyst containing keratin, adherent to the skin, mobile on the deep plane; characteristic whitish content sometimes visible by transparency; cutaneous and not intratarsal location. |
| Xanthelasma | Flat yellowish lipid deposits in the periorbital palpebral dermis, with well-defined, non-cystic margins, often bilateral and symmetrical; sometimes associated with hypercholesterolemia; no intra-tarsal cystic component. |
| Capillary hemangioma or vascular malformation | Purplish-red, compressible lesion, sometimes pulsatile; whitens on in vitro pressure; clinical appearance different from firm, non-vascular chalazion |
Treatment options
Chalazion treatment is adapted to the age of the lesion, its size, its impact on vision and the patient's history. It follows a progression of therapeutic steps:
| Treatment | Practical details | Indications and efficacy |
|---|---|---|
| Warm compresses and palpebral massage | Apply a clean compress soaked in warm water (40 to 45°C) to the closed eyelid for 5 to 10 minutes, 3 to 4 times a day; followed by a gentle massage from the edge of the eyelid towards the gland orifices to encourage evacuation of glandular contents. | First-line treatment for any acute or recent chalazion; heat softens the thickened meibum and helps reopen the obstructed excretory orifice; effective in 25 to 50 % of cases if started early; must be continued for at least 4 to 6 weeks before considering another option |
| Palpebral hygiene | Daily cleaning of the palpebral free edge with a cotton swab soaked in diluted baby shampoo, specific palpebral wipes (Blephaclean, Blephagel) or sterile compresses; removal of scales and deposits from the free edge. | Essential in cases of associated blepharitis to treat the causative agent and prevent recurrence; proven effective in reducing the frequency of recurrent chalazion associated with chronic blepharitis. |
| Antibiotic-corticoid eye drops or ointments | Combination of a topical antibiotic (tobramycin, chloramphenicol) and a corticosteroid (dexamethasone) in eye drops or ophthalmic ointment, applied 2 to 4 times a day for 1 to 2 weeks. | Adjunctive treatment during the acute inflammatory phase to reduce swelling and local inflammation; antibiotic to prevent secondary superinfection; limited efficacy on encysted chronic chalazion; medical prescription required |
| Intralesional injection of triamcinolone | Injection of a delayed corticosteroid (triamcinolone acetonide 10 to 40 mg/mL) directly into the chalazion using a fine needle, after local anaesthesia; performed by a physician or ophthalmologist in consultation. | Resolution rate of 80 to 85 % after one or two injections; treatment of choice for persistent chalazions after 4 to 6 weeks of hot compresses, large chalazions, and chalazions in patients at high surgical risk; relative contraindication in dark-skinned subjects due to risk of local depigmentation; may be repeated once if resolution incomplete. |
| Incision and surgical curettage | Procedure performed under local anaesthetic by a physician or ophthalmologist; eversion of the eyelid, vertical incision of the inner (conjunctival) surface of the chalazion with a scalpel or scissors, curettage of the granulomatous and lipid contents of the cystic cavity; no sutures required for conjunctival approach. | Reference treatment for large, encysted chalazions that do not respond to hot compresses or corticosteroid injections; efficacy close to 100 %; recurrence possible if cyst wall is not completely excised; systematic biopsy of cyst wall recommended for recurrent chalazions in the same location to exclude sebaceous carcinoma. |
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We strongly advise against attempting to express or pierce a chalazion at home. This may lead to secondary bacterial superinfection, palpebral cellulitis, unsightly scarring or conjunctival damage. In the event of spontaneous fistulization of the chalazion, the lipid content usually drains through the inner conjunctival surface of the eyelid without serious complication, but a medical consultation is still recommended to assess healing and adapt management.
Management in children
Chalazion is common in children, and presents a number of particularities compared to adults that merit special attention:
- Children's chalazions are often larger than those of adults, and can induce transient astigmatism through mechanical corneal compression, which can affect the development of binocular vision and promote amblyopia («lazy eye») if they persist for several months at the age of visual acquisition (before age 7); ophthalmological follow-up is recommended for any large chalazion in children under age 7.
- Warm compresses remain the first-line treatment in children, but their application requires the child's cooperation and adult supervision to avoid burns; warm compresses are preferable to very hot compresses in young children.
- Intralesional injection of corticosteroids is feasible in children, but often requires light sedation or brief general anesthesia, depending on age and cooperation. This often leads to surgical incision under general anesthesia on an outpatient basis for persistent, large chalazions in children under 5 or 6 years of age.
- Recurrences are frequent in children, due to the difficulty of maintaining rigorous palpebral hygiene and the tendency to rub the eyes; educating parents and children about regular palpebral hygiene is essential to reduce recurrences.
Prevention and palpebral hygiene
Preventing chalazions relies mainly on regular maintenance of eyelid and meibomian gland health:
- Daily palpebral hygiene - gentle cleansing of the palpebral free edge with a suitable product (palpebral wipes, saline solution) - particularly essential for people suffering from chronic blepharitis or acne rosacea.
- Apply preventive hot compresses (2 to 5 minutes a day) to closed eyelids in predisposed subjects to maintain meibum fluidity and the permeability of glandular orifices.
- Carefully remove eye makeup every night before bedtime, paying particular attention to the free edge of the eyelid and the root of the lashes, and avoiding makeup on the inner edge (waterline) of the eyelid, which directly obstructs the openings of the Meibomius glands.
- Avoid rubbing your eyes, which can deposit skin bacteria in the glandular orifices and promote obstruction.
- Active, long-term treatment of chronic blepharitis or underlying acne rosacea, which are the main causes of recurrent chalazions; long-term oral tetracyclines (doxycycline 100 mg/day) can be prescribed for ocular rosacea.
- In cases of dry eye syndrome associated with Meibomian gland dysfunction, lipid-based tear substitutes (liposome-based artificial tears), omega-3 supplements and Intense Pulsed Light (IPL) devices available in ophthalmology practices can improve Meibomian gland function and reduce recurrences.
Signs requiring prompt medical attention
Seek immediate medical attention in the event of rapid, painful swelling of the eyelid, extending beyond the palpebral margin into the cheek or orbit, accompanied by fever, diffuse redness of the eye and periorbital tissues, and/or restricted eye movement: these signs suggest orbital or preseptal cellulitis, a serious infectious complication requiring urgent antibiotic therapy, or even hospitalization. A chalazion recurring in the same location in a patient over 40, or associated with localized eyelash loss or an atypical appearance (ulceration, induration), must be evaluated by an ophthalmologist for biopsy to exclude sebaceous carcinoma or other palpebral cancer.
For persistent or recurrent chalazion, or for any palpebral lesion whose nature is uncertain, a consultation at Clinique Omicron allows for a structured medical evaluation and referral to an ophthalmologist if necessary, at one of our points of service in Quebec or via telemedicine. To book an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron provides assessment and treatment of common palpebral conditions, including chalazion, at its several points of service in Quebec and via telemedicine. A physician or specialized nurse practitioner (SNP) can confirm the diagnosis, distinguish a chalazion from a stye or other palpebral lesion, initiate the appropriate treatment and refer to an ophthalmologist in the event of a persistent, large or atypical lesion requiring a corticosteroid injection or surgery. To book an appointment, visit cliniqueomicron.ca.
The contents of this page are provided for information purposes only and do not replace the advice of a qualified healthcare professional. Consult a physician for any persistent ocular or palpebral symptoms or lesions of an uncertain nature.
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