Chalazion

  SIGNS AND SYMPTOMS
Patients will present with one or many focal, hard, painless nodules in the upper or lower eyelid. They may report some enlargement over time, and there may be a history of a painful lid infection prior to the chalazion development, but this isn't always the case. Chalazia are often recurrent, especially in cases of poor lid hygiene or concurrent blepharitis.

PATHOPHYSIOLOGY
A chalazion is a non-infectious, granulomatous inflammation of the meibomian glands. The nodule itself consists of many types of steroid-responsive immune cells, including connective tissue macrophages known as histiocytes, multinucleate giant cells, plasma cells, polymorphonuclear leukocytes and eosinophils.

A chalazion may be a residual aggregation of inflammatory cells following an eyelid infection such as hordeola and preseptal cellulitis, or may develop from the retention of meibomian gland secretions.

MANAGEMENT
Chalazia are non-infectious collections of immune cells that require intensive steroid therapy. Because chalazia reside deep under the skin, no topical medications will be able to penetrate sufficiently. About 25 percent of chalazia resolve spontaneously. For those that don't, instruct the patient to apply a hot compress to open the glands, then to digitally massage the area to break and express the nodule, up to four times a day.

If this is ineffective, inject triamcinolone acetonide (Kenalog) 5mg/ml or 10mg/ml directly into the chalazion (some practitioners have advocated concentrations as high as 40mg/ml, but this is not standard practice). Approach the lesion from the palpebral side, and inject 0.05 to 0.3ml in standard form, using a tuberculin syringe and 30-gauge needle. You may want to use a chalazion clamp and topical anesthesia, but this is not absolutely necessary. Usually the patient is markedly better one week later, but you may need to re-treat extremely large chalazia. If the chalazia persists even after a second steroid injection, or if the patient cannot tolerate the procedure, excise the remaining lesion using a curette under local anesthesia as a last resort.

CLINICAL PEARLS

Intralesional steroid injection is contraindicated for patients with dark skin, since the procedure can cause depigmentation which often persists for months, or is permanent. This is especially likely if the point of injection is on the skin, but may occur even if injecting through the palpebral conjunctiva.
Biopsy any recurrent chalazia, especially those following surgical excision, to rule out a particularly deadly malignancy known as sebaceous gland carcinoma.