A SIGNIFICANT INCREASE in astigmatism, especially in one eye, immediately raises questions for the eyecare provider. What could be the cause?

Consider a recent patient: A 61-year-old Caucasian female presented with the complaint of a “lump” on her right upper eyelid.

Patient refraction at the current examination:

Right eye: –1.25 –0.75 x 106 20/20Left eye: –1.75 –0.25 x 180 20/20

Patient refraction one year ago:

Right eye: –1.25DS 20/20
Left eye: –1.50 –0.25 x 177 20/20

Her slit lamp exam revealed a painless 8mm chalazion in the middle aspect of her right upper eyelid. The rest of her eye exam was normal for both eyes.

Do chalazions typically induce astigmatism or could the true cause of her increase be elsewhere?

CHALAZION BACKGROUND

Eyecare providers are well aware that a chalazion is a focal and chronic inflammation of the eyelid resulting from an obstructed meibomian gland (Vagefi, 2017). Often associated with rosacea and posterior blepharitis, chalazion symptoms start as mild inflammation and tenderness that continue over weeks to months. What may be less well known is that if substantially large, a chalazion may press on the globe and induce astigmatism (Vagefi, 2017).

Do all chalazions induce corneal astigmatism? A recent, large study of children ages 6 months to 6 years old discovered that the frequency of astigmatism was significantly higher when the chalazion was greater than 5mm in size, located in the middle-upper eyelid, and when one or two chalazia were present (Ouyang et al, 2022). The frequency of against-the-rule and oblique astigmatism was significantly higher in children who had chalazion versus the control group (Ouyang et al, 2022). Similarly, a study involving adults found significantly greater oblique astigmatism when chalazia were large and located in the upper eyelid (Jin et al, 2017).

Conservative treatment for chalazion includes warm compresses, antibiotics, and ophthalmic steroid ointments (Park and Lee, 2014) (Figure 1). If conservative treatment is not successful, then corticosteroid injection or surgical excision can be utilized (Park and Lee, 2014).

Is it likely that treatment will resolve the induced astigmatism or is this a permanent side effect? One study found that two months after surgical excision of large chalazia (greater than 5mm), there was a significant decrease in corneal astigmatism as well as a significant improvement in uncorrected distance visual acuity (Park and Lee, 2014). Surgical excision of a large, upper lid chalazion was recommended, as it decreased corneal astigmatism and improved uncorrected distance visual acuity (Park and Lee, 2014).

Prescribing for astigmatism? It is important to address chalazion treatment prior to prescribing for new or induced astigmatism. The induced astigmatism may resolve with treatment of this common lid condition.

PATIENT UPDATE

Conservative treatment did not eliminate the chalazion for the above-mentioned patient. The patient is scheduled for surgical excision of her chalazion. Based on current treatment and typical outcomes, the hope is that the induced astigmatism will resolve after a few months. CLS.

References

1. Vagefi MR. Lids & Lacrimal Apparatus. In: Riordan-Eva P, Augsburger JJ, eds. Vaughan & Asbury’s General Ophthalmology, 19e. New York, NY: McGraw-Hill Education; 2017. Available at accessmedicine.mhmedical.com/content.aspx?aid=1144467143. Accessed June 2, 2023.
2. Ouyang L, Chen X, Pi L, Ke N. Multivariate analysis of the effect of Chalazia on astigmatism in children. BMC Ophthalmol. 2022 Jul;22:1-10.
3. Jin KW, Shin YJ, Hyon JY. Effects of chalazia on corneal astigmatism : Large-sized chalazia in middle upper eyelids compress the cornea and induce the corneal astigmatism. BMC Ophthalmol. 2017 Mar;17:1-9.
4. Park YM, Lee JS. The effects of chalazion excision on corneal surface aberrations. Cont Lens Anterior Eye. 2014 Oct;37:342-345.