treatment plan
Managing Chalazia
BY WILLIAM L. MILLER, OD, PHD

The chalazion represents one of the more common problems we encounter in the eyelid. Rarely painful, it can cause visual disturbances through its physical impingement on the cornea. Additionally, if its presentation is more internal it may affect the

It can also affect the movement or positioning of contact lenses if its presentation is more internal. Just as important, chalazia create an unsightly aesthetic issue for patients. You'll note varying degrees of redness either on the superficial dermis or on the palpebral conjunctiva, many times wholly dependent on the size of the chalazion.

Recognizing a Chalazion

Diagnosing a chalazion is rarely difficult, but keep in mind that other lid lesions (squamous, basal and sebaceous carcinomas) can mimic this problem. Obtain a pathological analysis of any chalazia-like bump that appears uncharacteristic, tends to recur or doesn't respond to therapy to rule out other lid anomalies.

On histopathologic evaluation, a chalazion represents a lipogranulamatous inflammation of the Zeiss or meibomian glands. The granuloma forms when the secretory component of the glands is blocked. This focal lesion is mainly composed of epithelioid cells, macrophages, plasma cells, giant cells, neutrophils and lymphocytes.

Start Out Conservatively

Antibiotic therapy is of little value when treating chalazia because chalazia represent noninfectious inflammatory lesions. Most initial therapies start with a conservative approach using warm compresses and digital expression.

Successful amelioration of the chalazion with conservative therapy has ranged in the literature from 25 percent to 77 percent. A study from Britain (Jackson TL 2000) found that nearly 30 percent of chalazia resolved after conservative therapy. The wide range of success most likely resulted from the size and age of the respective chalazion being treated. Success also hinges on the compliance of the patient to routinely perform the outlined conservative therapies.

Take a Step Further

When conservative therapy is unsuccessful or when the patient desires a quick resolution, consider injectable treatment, specifically a subcutaneous steroid injection either within or around the chalazion. Depending on the presentation of the chalazion, you can perform the injection in either a percutaneous or transconjunctival manner. Use a 0.1mL or 0.2mL bolus of triamcinolone acetate (10 mg/ml or 40 mg/ml suspension) in a tuberculin syringe. You can also replace the triamcinolone with dexamethasone in a 20 mg/ml or 40 mg/ml dose, although the latter medication is frequently used for small and softer lesions because it does not remain in the site long enough to have maximal efficacy.

A recent study out of Hong Kong (Ho SY 2002) showed that chalazia resolved with injectable treatment in nearly 90 percent of cases, with 54 percent resolving after only one injection. Common practice is to reserve injections for smaller, more defined, rigid chalazia, but in the Hong Kong study there were no differences in outcome based on the size or duration of the lesion.

Steroid injections can cause skin depigmentation, dermis atrophy and, although rare, globe perforation.

If All Else Fails . . .

If the chalazion does not respond to the above therapies, then the last course of action is an incision and curettage, which is also indicated for patients who desire quicker resolution or for lesions that are large.

An often painful perilesional anesthetic is typically required before incision and curettage, however a recently reported decrease in pain has been noted when lignocaine 2% gel is substituted for the anesthetic injection. You can apply this gel to the skin or directly to the conjunctival surface.

Dr. Miller is a member of the American Optometric Association and serves on its Journal Review Board. Reach him at wmiller@uh.edu.