Emergency Medicine News:
Wiler, Jennifer L. MD, MBA
Dr. Wiler is an assistant professor of emergency medicine and the vice chair of clinical quality, patient safety, and process improvement at the University of Colorado Denver School of Medicine and an adjunct assistant professor of emergency medicine at the Washington University School of Medicine in St. Louis.
A 3-year-old boy presents with a right lower eyelid swelling. His parents state that it has developed over the past three days. He has no recent cold, trauma, tearing, or discharge. He has no medical problems, and his immunizations are up to date.
What is the diagnosis, and what is the recommended treatment? See next page.
Chalazion, also known as a meibomian gland lipogranuloma, is an acute or chronic obstruction of the meibomian or Zeis gland, which results in a tender, erythematous, granulomatous inflammatory cyst within the eyelid. Meibomian glands are embedded in the tarsal plate of the eyelid. They produce meibum, an oily fatty substance that prevents evaporation of tear film. This gland can be visualized as small punctate hypopigmented dots near the tarsal plate when the eyelid is averted.
Chalazia generally are a form of sterile inflammation secondary to obstruction, and tend to be larger but less painful then hordeolums, which are caused by purulent infection of the cilium. (Clin Pediatr [Phila] 2009;48:588.) It may be difficult to differentiate a chalazion from a hordeolums clinically.
The exact incidence of chalazia is unknown, but dermatologic skin conditions including acne rosacea and seborrhoeic dermatitis are known to predispose to meibomian gland dysfunction. (BMJ 2010;341:c4044.) Blepharitis (chronic inflammation of the eyelid resulting in dry eyes) is also known to predispose to chalazion formation. Chalazia are more common in adults than children, and are thought to be related to hormone changes. Patients with elevated blood lipids and an impaired immune system are also at risk.
Patients may report a tender or nontender eyelid lump that may change size daily. (Emerg Med Clin North Am 2008;26:57.) Ulcerative or destructive changes on the lid skin are not typical of a chalazion and should be referred to an ophthalmologist because this may be a sign of malignancy. Recurrent chalazia are also of concern for sebaceous gland carcinoma, squamous cell carcinoma, basal cell, microcystic adnexal carcinoma, ocular leishmaniasis (Eye [Lond] 2009;23:737), or tuberculosis (Eye [Lond] 2001;15[Pt 5]:674), and should be referred for specialist evaluation. Depending on the size and duration of the mass, chalazia may be associated with decreased visual fields from eyelid enlargement, and local pressure may create a relative astigmatism. The eyelid should be inverted to determine if other chalazia are present.
The diagnosis of chalazia is clinical, and they are typically self-limiting and benign. The mainstay of treatment is daily warm compresses and lesion massage. Nearly 50 percent will resolve with conservative management only. (Clin Experiment Ophthalmol 2007;35:706.) The Wills Eye Manual (Philadelphia: Lippincott Williams & Wilkins, 2012) recommends topical antibiotics, but other sources claim there is no benefit. (BMJ 2010;341:c4044.) A recent Cochrane Review concluded that more studies were needed to determine the effectiveness of nonsurgical interventions for treating hordeolums. (Cochrane Database Syst Rev. 2010 Sep 8;:CD007742.) Chalazia were not studied in this review, but the information in the article is helpful when considering the current discrepancy in treatment recommendations.
Incision and curettage or intralesional steroids (triamcinolone) can be performed if lesions do not resolve in one or two months and the patient would like it removed. (Eur J Ophthalmol 2003;13[9-10]:798.) The chalazion in this patient resolved after eight weeks of daily warm compresses, massage, cleaning the eyelid margin, and antibiotic ophthalmic ointment, leaving a small hyperpigmented lesion.
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