Chalazion: treatment, incision and preventing recurrences

What is a chalazion? Anatomy and mechanism

Within its thickness, the eyelid contains two rows of Meibomian glands: roughly 25 to 40 per eyelid. These glands secrete the lipid phase of the tear film, which prevents the tears from evaporating and lubricates the surface of the eye with each blink. When the excretory duct of one of these glands becomes blocked — through thickening of the sebum, inflammation of the eyelid margin or low-grade chronic infection — the lipids build up inside the gland.

This build-up triggers a granulomatous reaction: the immune cells (histiocytes, plasma cells) organise themselves in a crown around the lipid contents, forming a fibrous shell. It is this encapsulated cyst, firm to the touch and barely painful, that is called a chalazion — from the Greek khalaza, hailstone. The upper eyelid is affected more often than the lower one, simply because it contains more glands.

Symptoms: recognising a chalazion

A chalazion usually follows a characteristic sequence when it appears. In the first few days, the area is sometimes red and slightly painful, which can suggest a stye. Then the acute inflammation subsides and a firm nodule remains, painless or barely tender, mobile under the finger.

• Firm nodule palpable under the skin of the upper or lower eyelid, not adherent to the overlying skin.
• Visible bulge at the surface of the eyelid, sometimes distorting it depending on its size.
• Conjunctival redness visible on the inner surface of the turned-over eyelid, a sign of the inflammation.
• Mild visual disturbance in the case of a large chalazion pressing on the cornea, which can induce a temporary, fluctuating astigmatism.
• Sensation of a foreign body or of a heavy eyelid, especially at the end of the day.
• Reflex watering linked to conjunctival irritation or to an associated dry eye.

Causes and contributing factors

A chalazion can occur in anyone, but certain situations clearly increase how often episodes happen:

Chronic blepharitis and Meibomian gland dysfunction

This is the main cause of recurrences. Blepharitis thickens the glandular secretions and favours repeated blockages. Meibomian gland dysfunction (MGD) — very common in people who spend a lot of time in front of a screen, because blinking becomes less frequent and the glands become congested — shares the same pathophysiology. A recurrent chalazion is often the sign of an untreated underlying blepharitis.

Rosacea and seborrhoeic dermatitis

Ocular rosacea very often comes with blepharitis and MGD. Seborrhoeic dermatitis of the scalp and eyebrows also favours blockages by changing the composition of the eyelid sebum. These dermatological conditions warrant specific treatment to reduce how often chalazia occur.

Other contributing factors

• Insufficient eyelid hygiene: stagnation of sebum and scaly debris on the eyelid margin.
• Prolonged use of contact lenses, which alters the dynamics of the tear film.
• Hormonal contexts: certain periods (pregnancy, puberty) favour an altered sebaceous secretion.
• Stress and fatigue, which reduce the blink rate and diminish the quality of the tear film.
• A history of chalazion: once a gland has been weakened, the risk of recurrence at the same site is increased.

Chalazion or stye? The diagnosis

Chalazion and stye are frequently confused. The following table summarises the essential distinguishing criteria to guide how to proceed.

The distinction is not always obvious early in the course. A neglected stye can leave a residual chalazion once the infection has resolved. The consultation makes it possible to confirm the diagnosis and to avoid treating a lesion the wrong way.

Medical treatment: compresses and massage

Moist heat applied to the eyelid thins the thickened secretions and can relieve the blockage, allowing a spontaneous resolution. This is the first-line treatment, to be started from the very first days.

Warm compress protocol

• Apply a clean compress soaked in lukewarm water (or a reusable thermal heating compress) to the closed eyelid, 2 to 4 times a day, 5 to 10 minutes at each application.
• Immediately afterwards, perform a gentle massage of the eyelid margin by pressing lightly towards the eye with a circular movement, to push the secretions towards the openings of the glands.
• Clean the eyelid margin with a suitable eyelid-hygiene product (wipe or solution) to remove the deposits that favour the blockage.
• Keep up the protocol for at least 4 to 6 weeks before considering another form of management.

Prescribed local treatments

If an associated infectious blepharitis is present, antibiotic and anti-inflammatory eye drops or ointments may be prescribed as a complement. Intralesional corticosteroid injections are sometimes offered for persistent chalazia or ones in a delicate position, but incision remains the fastest and most reliable method for an encysted chalazion.

Incision and curettage at the office: how it works

When the chalazion persists beyond 4 to 6 weeks despite well-conducted medical treatment, or when it is large, distorting or interfering with vision, incision and curettage is the most effective solution. It is carried out at the office, without hospitalisation.

The 4 steps of the procedure

1. Local anaesthesia: an injection of lidocaine into the thickness of the eyelid numbs the area. The injection is the least pleasant moment of the procedure, but it lasts a few seconds.
2. Eversion of the eyelid: a chalazion clamp is placed to turn the eyelid over and expose the inner (conjunctival) surface, where the incision will be made — invisible from the outside.
3. Incision and curettage: a small vertical incision is made on the conjunctiva, opposite the cyst. The contents (solidified lipids, inflammatory debris) are evacuated with a curette. The fibrous shell is also curetted to limit the risk of recurrence at the same site.
4. End of the procedure: no sutures are needed. An antibiotic and anti-inflammatory ointment is applied straight away. A light occlusive dressing may be placed for a few hours.

After the procedure

The aftermath is usually straightforward:

• Eyelid swelling is usual over the first 24 to 48 hours, sometimes with a small bruise (a discreet haematoma). Normal and transient.
• An antibiotic and anti-inflammatory eye drop or ointment is prescribed for 5 to 7 days.
• Avoid rubbing the eye during healing and wearing eye make-up for 5 to 7 days.
• Vision is not affected by the procedure itself. If a transient blur is noted, it is linked to the ointment or to slight conjunctival swelling.
• Return to activity is possible straight away for sedentary work not exposed to dust.

Preventing recurrences: eyelid hygiene

Recurrence is common in patients with an untreated underlying blepharitis or MGD. A regular eyelid-hygiene protocol is the most effective measure to reduce how often it happens.

Recommended daily routine

• In the morning: warm compresses for 5 minutes, then gentle massage of the eyelid margin. Clean the eyelashes with a dedicated wipe (hypoallergenic, fragrance-free).
• In the evening: fully remove eye make-up before going to bed. Avoid waterproof mascaras, which need harsh products to be removed.
• Reduce prolonged screen time without blinking, or adopt the 20-20-20 rule (every 20 minutes, look at something 6 metres away for 20 seconds) to stimulate blinking.
• If you wear contact lenses, follow the hygiene instructions and do not sleep with your lenses in.

Treating the underlying cause

When chalazia recur frequently, the consultation should make it possible to identify and treat the cause: chronic blepharitis with local or oral antibiotic therapy depending on the germ, ocular rosacea with specific dermatological management, MGD with glandular expression at the office (a debridement of the Meibomian glands) or a thermal pulsation device. An associated dry eye should also be managed, as it keeps the inflammation of the eyelid margin going.

When to see an ophthalmologist?

A consultation is not systematically needed for a first, small chalazion, but it is advisable in the following situations:

• The nodule persists beyond 3 to 4 weeks despite daily warm compresses.
• It grows progressively or distorts the appearance of the eyelid.
• It interferes with vision by pressing on the cornea.
• It is a frequent recurrence at the same site, or there are several chalazia at once.
• The nodule comes with significant redness, diffuse swelling or a fever (suspicion of pre-orbital cellulitis, a medical emergency).
• You are not sure of the diagnosis: a hard, fixed, painless nodule may have another origin.
• It concerns a child: medical treatment is often enough, but the decision to perform an incision should be made by a paediatric ophthalmologist.

Frequently asked questions

Sources

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This content is informative and does not replace an ophthalmological consultation. Every situation is individual and should be discussed in consultation with your ophthalmologist.