I’ll be the first to admit, the eyelids are fantastic. I really appreciate them. They keep the eyeball healthy and warm and safe. That being said, sometimes the eyelids can be a real dick, like when you get a chalazion. Let’s get started.
No ophthalmology lesson would be complete without an introductory section about vocabulary. Please, don’t go, it’s not that bad. Let’s start with some definitions.
A chalazion is a blocked meibomian gland.
A meibomian gland is an oil-producing gland in the eyelid.
An eyelid is a windshield wiper for the eye.
Great, now that we’ve cleared that up, what’s the difference between a chalazion and a stye? Technically speaking, a “stye” or hordeolum, as the textbooks and boring nerds like to call it, denotes the presence of infection, so it’s basically a chalazion that is infected. However, 9 times out of 10 a stye isn’t actually a stye, it’s just a chalazion. It’s an accumulation of oil in the eyelid that has incited an inflammatory response, but there is no active infection present.
Now I know what you’re thinking, who gives a shit? Nobody really. I will frequently use the term stye with patients because they are most familiar with that term, even though the diagnosis is almost certainly a chalazion, but I always reassure the patient that there is no infection present.
could this be cellulitis?
Before we get into the treatment of a chalazion, let’s talk about eyelid infections. The inflammation surrounding a chalazion can be intense, sometimes resulting in dramatic eyelid swelling. This could easily be misdiagnosed as a pre-septal cellulitis, the most common eyelid infection. However, a couple key differences between an inflamed chalazion and pre-septal cellulitis will help you come to the correct diagnosis.
Inflamed chalazia will have focal erythema and edema right above the eyelashes. The swelling can involve the entire eyelid, but there will always be a big lump near the eyelid margin where those pesky meibomian glands live.
Pre-septal cellulitis always presents with history of trauma. Surgery, fingernail scratch, popped
zit, aggressive fake lash application. Something broke the skin to allow the infection to get up in there.
So you have a patient with a chalazion. Now what?
The goal is to open up the blocked gland. While examining the patient at the slit lamp, I like to press right on that collection of oil and see what comes out. Few things are more satisfying than a nice burst of thick meibomian gland oil from an obstructed gland, but then again, I’m a weirdo. For the vast majority of primary care providers without access to a slit lamp or a desire to manually express human glands, ask the patient to start doing hot compresses. Compresses are the mainstay of treatment for this condition. Here’s my spiel that I give roughly 3,400 times per day:
“To do a hot compress, use a hot washcloth or eye mask, AS HOT AS YOU CAN TOLERATE WITHOUT BURNING YOURSELF, and hold it on your closed eyes for 5 minutes, applying intermittent light pressure. Do this at least 2 times per day, 3-4 times if possible.”
I shouldn’t have to tell people not to burn themselves, but then again, people are out there tattooing their eyeballs and using homeopathic eye drops made of their own urine, so who knows?
90% of chalazia will resolve spontaneously with dedicated heat and massage for about 2 weeks. For patients who have significant inflammation, are in pain, or have a wedding next week and need faster resolution, I will often prescribe an antibiotic/steroid combination ointment or drop, such as Maxitrol. If there is a relative contraindication to ophthalmic steroid use such as steroid-induced glaucoma, I will prescribe erythromycin ointment.
Some diseases predispose to developing chalazia, like rosacea and chronic blepharitis. For these patients, oral doxycycline 100mg BID for 2 weeks works like a dream. Doxycycline inhibits matrix metalloproteinase-9, which helps decrease inflammation on the eyelid margin and allows those glands to open up. For kids with severe blepharoconjunctivitis and multiple styes, I will sometimes prescribe a 5 day course of oral azithromycin (z-pak).
“Cut it out of me, doc”
If there has been no improvement after 2 weeks of dedicated hot compresses +/- topical and systemic antibiotics/steroid, I will offer incision and drainage. The reason I like to wait at least 2 weeks is because most chalazia resolve spontaneously, but also I don’t want to cut on an acutely inflamed chalazion. The screams will be heard across state lines. Better to control the inflammation and try to decompress the oil a bit before opening up the gland with a very sharp knife.
when to consult ophthalmology
If you are comfortable with your diagnosis, send these patients to ophthalmology in 2-3 weeks if symptoms have not improved with conservative treatment. If the patient is particularly unhappy or the amount of eyelid swelling and redness you see makes you raise your eyebrows and/or gives you the willies, send the patient over for a next available appointment. I’ve said this before, but any private practice that knows what they’re doing will be able to get a patient in to see somebody within 2-3 days.