CHAPTER 65 Chalazion and Hordeolum
Patients with a chalazion or hordeolum, focal inflammatory conditions of the eyelids, are frequently encountered in primary care. Invariably they complain of a “stye.” Both conditions may be treated by the prudent nonophthalmologist using a minor surgical procedure in the office setting. However, care must be taken not to injure the eye, the eyelid, or sensitive components, particularly the lacrimal drainage system (“tear ducts”) or the eyelid margin.
A chalazion (Fig. 65-1) is an acute or chronic granulomatous inflammation of a meibomian gland in the eyelid. A hordeolum is an acute abscess of a meibomian, Zeis’, or Moll’s gland (see Fig. 65-10). An internal hordeolum points onto the conjunctival surface of the lid, whereas an external hordeolum points onto the external surface of the skin or the margin of the lid.
The meibomian glands are basically sebaceous glands located deep within both eyelids (Fig. 65-2). They constantly produce a lipid material that drains through long ducts and emerges from orifices at the eyelid margin. This lipid material then enters the tear film to help keep the surface of the eye lubricated while also slowing evaporation of the tears.
Meibomian secretions are naturally viscous, but under certain conditions they become thick enough to plug the duct of the gland. Because the gland continues to produce secretions, they must go somewhere (similar to a sebaceous cyst); consequently, the secretions eventually leak between the cells of the gland into the surrounding tissue of the eyelid. Here, the secretions incite a chronic granulomatous inflammatory reaction (chalazion). As more secretions are produced, the inflammation worsens and it may smolder chronically, sometimes for a year or longer.
Clinically, the inflammation causes localized swelling, edema, or a nodule within the lid, sometimes associated with erythema and mild tenderness. A chalazion may be located at the lid margin or up to a few millimeters away. At times it may be prominent externally, but more commonly a chalazion will be found on the inner (palpebral conjunctiva) surface of the lid. Associated inflammation may cause a soft or even liquid center, and patients may report spontaneous drainage internally, externally, or through the lid margin, which may lead to clinical improvement or resolution. A chalazion may also wax and wane.
Some people experience multiple chalazia over time or even concurrently. Multiple chalazia are more commonly seen in people with acne rosacea or chronic blepharitis. Chronic blepharitis is characterized by eyelid margin inflammation, thickening, and erythema associated with bacterial colonization and crusting at the base of the eyelashes. Chronic blepharitis usually requires a slit-lamp examination to make the diagnosis (see Chapter 67, Slit-Lamp Examination); even with a slit lamp, the findings are often subtle and not easily detected by the nonophthalmologist.
In contrast to a chalazion, a hordeolum is an acute bacterial abscess of a meibomian, Zeis’, or Moll’s gland (see Fig. 65-2). Hordeola are classified as internal or external based on the primary anatomic focus of the inflammation (which is usually obvious). Typically characterized by an acute tender mass within the eyelid, associated with erythema and a collection of pus, hordeola are often accompanied by acute cellulitis of the eyelid. Such cellulitis, in turn, is characterized by erythema, edema, and tenderness of the surrounding skin. (“Eyelid cellulitis” is a different, much more localized entity than the less common “orbital cellulitis,” a systemic, vision- and life-threatening condition with which the patient is toxic with a high fever.) A hordeolum usually drains spontaneously at 5 to 7 days, often relieving the symptoms. Hordeola are frequently associated with Staphylococcus infections and acute blepharitis, and these both usually respond to antibiotics.
To differentiate a chalazion from a hordeolum can be a clinical challenge. Although a hordeolum is usually more tender and tense with obvious fluctuance, a chalazion may have a liquefied center; however, it is usually not a collection of pus. The presence of significant eyelid cellulitis also usually suggests a hordeolum, but a chalazion may be associated with a degree of surrounding erythema and edema (although it is usually to a lesser degree). The natural history of a hordeolum is usually more acute; yet, a chalazion can present acutely. It may also be important to differentiate a chalazion or hordeolum from other eyelid disorders. If the swelling is located nasal to the medial canthus (the corner where the upper and lower eyelids meet), the patient likely has dacryocystitis rather than a chalazion or hordeolum. In this situation, strongly consider prompt referral to an ophthalmologist because dacryocystitis can lead to serious sequelae. Because of the facial anatomy, bacterial dacryocystitis can dissect posteriorly to the cavernous sinus and beyond, with grave consequences.