Chalazion (Meibomian cyst)
Chalazion is a chronic inflammatory granuloma of the meibomian glands caused due to the obstruction of the gland orifices and thereby stagnation of the secretions.
Meibomian glands are the modified sebaceous glands present in the tarsal plates (thick fibrous tissue) of both upper and lower lids of each eye. There are about thirty to forty glands in the upper tarsal plate and about twenty to thirty in the lower tarsal plate. These glands secrete the outer lipid layer of the tear film covering the front surface of eyeball. The ducts of the glands are arranged vertically and open on the intermarginal strip (lying between posterior and anterior lid margin) behind the row of eyelashes. Similar modified sebaceous glands associated with eyelash follicles are known as glands of Zeis.
There may be acute infection of the secretions in Chalazion leading to small abscess formation known as Hordeolum internum. Similarly, glands of Zeis may develop acute infection and develop small abscess known as Hordeolum externum(stye).
Br J Ophthalmol 2011; 95:590 doi:10.1136/bjo.2008.146704
Kanski, Jack J. Clinical Ophthalmology, A Systematic Approach.Third Edition.UK. Butterworth Heinemann, 1994.
Chalazion usually present as small, painless, firm roundish lesion over the tarsal plate area in the lid skin.
Chalazion may present as polypoid mass (pyogenic granuloma) by rupturing through the tarsal conjunctiva.
Marginal chalazion may present at the eyelid margin.
There may be a single or multiple chalazia (plural of chalazion).
A chalazion of the upper lid may press upon the cornea and may cause blurred vision due to induced astigmatism (a kind of refractive error).
An infected chalazion (Hordeolum internum) may cause painful inflamed swelling.
Chalazion may be recurrent. Meibomian gland carcinoma or basal cell carcinoma may present as ‘recurrent chalazion’ and therefore, requires further investigations.
Chalazion occurs due to blockage of the orifice of meibomian gland duct. Blockage of ducts may be potentiated due to certain associated conditions such as :-
A patient may have painless swelling present on the lids for days and weeks and may seek attention for cosmetic reason. There may be single or multiple swellings. Frequently, there is history of previous similar occurrences. A patient may present with diminution of vision especially with large centrally placed chalazion of upper lid pressing onto the cornea. It may lead to acquired with- the- rule astigmatism or acquired hypermetropia.
It may present with painful inflamed swelling which may be infected. Severe infection may lead to preseptal cellulitis (swelling of the lids). Recurrent chalazion occurring at the same place may require further investigations to rule out any potential malignancy.
On examination, there is firm, nonerythematous, nonfluctuant and nontender swelling. Conjunctival surface under the lid may show dilated meibomian gland. A gentle compression of adjoining glands may produce inspissated toothpaste like material which is clear and oily otherwise. Conjunctiva adjacent to the dilated meibomian gland may be congested. Draining preauricular lymph nodes are not swollen unless there is secondary infection of the chalazion.
There may be features of associated conditions like acne rosacea, seborrhoea or chronic blepharitis. Rosacea shows characteristic features like facial erythema, spider naevus, telangiectasia or there may be associated rhinophyma. Seborrhoea is associated with excessive oily sebaceous secretion. There may be scales or ulcerative lesions on the lid margins in cases of chronic blepharitis.
Chalazion should be distinguished from conditions like:
- Squamous cell, basal cell and meibomian cell carcinoma
- Capillary and cavernous haemangioma
- Molluscum contagiosum
Fine needle aspiration cytology in recurrent chalazia may help in ruling out any malignancy.
Infrared photographic imaging of the meibomian glands on everted eyelids may show dilated meibomian gland. Adjoining glands on imaging may show inspissated secretions.
Small, inconspicuous and nonsymptomatic chalazia may resolve on its own and may not require any treatment. Chalazion may be managed conservatively or by surgical means.
1. Application of moist heat and lid massage may help in liquefaction of secretions, thereby facilitating drainage of sebaceous secretions.
2. Steroid injection into chalazion through transconjunctival route is a good alternative to surgery. It may be repeated in non responsive cases. A soluble aqueous preparation is preferred over crystalline suspension, to reduce side effects. Potential side effects are lid atrophy, hypopigmentation, visible depot of medicine if given subcutaneously.
3. Systemic antibiotics may be useful as prophylactic measure in patients with recurrent chalazia associated with seborrhoeic dermatitis, acne rosacea or chronic blepharitis.
1. Incision and curettage is the procedure conducted under local anaesthesia to evacuate the contents of chalazion in most of the cases.
2. Biopsy may be performed on the remaining edge of gland after incision and curettage in cases of recurrent chalazion to rule out the possibility of sebaceous cell carcinoma.
1. Lid notching: Incisions transgressing lid margin may result in notch formation.
2. Cutaneous fistula and scar formation: Deep incisions may lead to formation of cutaneous fistula or even scarring of the lid.
3. Granuloma formation: Inadequate curettage may lead to proliferation of tissue and granuloma formation.
4. Recurrence of chalazion: Chalazion may recur if it is not properly curettage to remove all the tissue including the lining of the affected gland.
5. Preseptal cellulitis may be associated with inflamed and infected chalazion.
6. Refractive errors like astigmatism and hypermetropia with associated diminution of vision may occur due to large centrally placed chalazion of upper lid.
7. Irritation and conjunctival redness may occur due to persistent drainage and swelling of chalazion.
8. Cosmetic deformity of lids due to swelling may be the reason for consultation.
9. Hordeolum internum may occur with associated inflammation following infection of chalazion.
10. Trichiasis (inward bending of eye lashes) or madarosis (loss of eye lashes) may occur with marginal chalazion.