Chalazion and Hordeolum

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INTRODUCTION A chalazion and hordeolum are focal inflammatory lesions of the eyelid that results from the obstruction of secretory glands. In a chalazion there is no acute bacterial infection, but rather a chronic inflammatory lesion with circumferential fibrosis. When this involves the meibomian glands they form a deep chalazion, whereas when there is involvement of the more superficial glands of Zeis in the dermis or glands of Moll associated with the pilosebaceous unit a more superficial chalazion results. A hordeolum is an acute bacterial abscess filled with pus and associated with pain and inflammatory signs. They can involve the meibomian glands (deep hordeolum) or the Zeis and Moll glands ( superficial hordeolum). Superficial hordeola are usually found near the eyelid margin where the Zeis glands are concentrated. Two-thirds of cha-lazia show mixed-cell cytology, and one-third are suppurating granulomas. The latter tend to occur in older patients with a longer duration of symptoms and larger lesions. When the impacted gland ruptures, extravasated lipid material produces a surrounding chronic lipogran-ulomatous inflammation. Both chalazia and hordeola often occur in patients with blepharitis and rosacea.

CHAPTER 8: ATLAS OF EYELID LESIONS ■ CHALAZION AND HORDEOLUM ■ 133

CLINICAL PRESENTATION A hordeolum presents acutely with pain, eyelid edema, and erythema, and it evolves into a subcutaneous nodule which may point anteriorly to the skin surface or through the posterior surface of the lid where the tarsus is closer to the conjunctival surface. Exuberant lesions will sometimes erode through the conjunctiva presenting as a type of pyogenic granuloma. They may drain spontaneously or under medical therapy. In contrast, chalazia usually present insidiously as a firm, painless mass. Multiple lesions of both types are not uncommon and very large lesions on the upper lid may even induce astigmatism and amblyopia in children.

Eyelid Erythema

HISTOPATHOLOGY A chalazion is a localized lipogranulomatous reaction to the sebaceous glands of the eyelids (either the meibomian glands or the glands of Zeiss). Obstruction of sebaceous gland ducts results in a granulomatous response surrounding vacuoles that remain when lipid is dissolved during histological processing. Epithelioid cells predominate in the granulomas, and the number of multinucleated giant cells is highly variable. Neutrophils may be prominent in early lesions, while lymphocytes and varying degrees of fibrosis are seen in more chronic chalazia. Chalazia arising from the meibomian glands may rupture into the conjunctival substantia propria or involve the dermis of the eyelid. Chalazia developing from a gland of Zeiss usually remain localized to the eyelid margin.

Chalazion Histology

DIFFERENTIAL DIAGNOSIS About 6 % to 7% of chalazia and hordeola are misdiagnosed at presentation, with about 1 to 2% actually being malignant. The differential diagnosis includes chronic inflammation, abscess, sebaceous cell carcinoma, and basal cell carcinoma.

TREATMENT Small hordeola may resolve spontaneously. Acute lesions are initially treated with hot compresses to encourage localization and drainage, combined with a topical steroid-antibiotic preparation. When further treatment is required the technique varies according to the stage and nature of a lesion. Chronic chalazia may be treated using intralesional corticosteroid injection or surgical drainage. Injection of soluble steroids such as tiramcinolone acetonide, can be effective but carries a very small risk of central retinal artery obstruction, the result of retrograde arterial infusion. It can also induce focal depigmentation in darker skinned patients. Inadvertent ocular penetration has been reported. If a viral etiology is suspected, steroids should be used only cautiously. Suppurating granulomas in long-standing chalazia respond better to surgery than to steroid injections so that larger, long-standing lesions (>8 months duration) are best treated surgically. When medical therapy or steroids fail to resolve the lesion surgical drainage is performed. This is best accomplished with vertical transcon-junctival incisions that allow adequate curettage of the lesion while limiting damage to surrounding meibomian glands. Thermal cautery of the cyst wall has no demonstrable effect on recurrence rate. In recurrent lesions, biopsy is necessary to exclude sebaceous gland carcinoma.

REFERENCES

Ben Simon GJ, Huang L, Nakra T, et al. Intralesional tiramcinolone acetonide injection for primary and recurrent chalazia: is it really effective? Ophthalmology 2005; 112:913-917. Dhaliwal U, Bhatia A. A rationale for therapeutic decision-making in chalazia. Orbit 2005; 24:227-230. Donaldson MJ, Gole GA. Amblyopia due to inflamed chalazion in a 13-month old infant. Clin Experiment Ophthalmol 2005; 33:332-333.

Goldberg RA, Shorr N. 'Vertical slat' chalazion excision. Ophthalmic Surg 1992; 23:120-122.

Hosal BM, Zilelioglu G. Ocular complications of intralesional corticosteroid injection of a chalazion. Eur J Ophthalmol 2003; 13:798-799.

Lempert SL, Jenkins MS, Brown SI. Chalazia and rosacea. Arch Ophthalmol 1979; 97:1652-1653. Ozdal PC, Codere F, Callejo S, Caissie AL, Burbier MN. Accuracy of the clinical diagnosis of chalazion. Eye 2004; 18:135-138.

Sendrowski DP, Maher JF. Thermal cautery after chalazion surgery and its effect on recurrence rates. Optom Vis Sci 2000; 77:605-607.

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Responses

  • rosarmosario
    What ti do with s chalazion inside the eyelid?
    6 years ago
  • taina tuhkasaari
    Do conjunctival granulomas meibomian settle spontaneously?
    6 years ago

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