Management

In the acute inflammatory phase, treatment consists of warm compresses and appropriate eyelid hygiene. Topical antibiotic or anti-inflammatory ocular medications may also be helpful. Acute secondary infection may be treated with an antibiotic directed at skin flora. Oral doxycycline, tetracycline, and azithromycin are commonly used, but there is insufficient supporting evidence from clinical studies. Tetracyclines and azithromycin have been shown in both in vitro and in vivo studies to modulate the expression of inflammatory mediators (matrix metalloproteinases, collagen production, interleukin-1, nitric oxide, and activated B cells), inhibiting bacterial lipase production and thereby improving the tear film balance. However, these medications are contraindicated in children and during pregnancy, and they require prolonged use that can be associated with allergy, gastrointestinal distress, photosensitivity, poor compliance, and multidrug resistance.

Occasionally, chronic, persistent chalazia require surgical management. In most cases, the greatest inflammatory response is on the posterior eyelid, and an incision through tarsus and conjunctiva is appropriate for drainage. Sharp dissection, curettage, and excision of all necrotic material, including the cyst wall, are indicated (Fig 10-15). This procedure results in a posterior marsupialization of the chalazion. Caution is required when removing inflammatory tissue at the eyelid margin or adjacent to the punctum. In rare cases, the inflammatory response is more severe on the anterior eyelid; in such cases, a skin incision is used. Given the risk of masquerade conditions, including sebaceous cell carcinoma, pathologic examination is appropriate for atypical or recurrent chalazia.

Figure 10-15 Incision and curettage of chalazion. A, The chalazion clamp is centered over the lesion and the eyelid everted. B, A number 11 blade scalpel is used to incise the tarsus vertically, stopping several millimeters from the eyelid margin. C, Lipogranulomatous material is drained. D, A curette can further remove the contents and excess fibrotic tissue or capsule can be excised.

(Courtesy of Cat N. Burkat, MD.)

Local intralesional injection of corticosteroids is sometimes employed as a less invasive option, but it can cause skin depigmentation and is less effective than surgical treatment. The combination of excision and steroid injection yields a 95% resolution rate.

• Wladis EJ, Bradley EA, Bilyk JR, Yen MT, Mawn LA. Oral antibiotics for meibomian gland-related ocular surface disease: a report by the American Academy of Ophthalmology. Ophthalmology. 2016;123(3):492–496.

Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.