What are the next steps for a chalazion (a small bump on the eyelid) that is resistant to antibiotics, after a 7-day course of Doxycycline (an antibiotic medication)?

Management of Antibiotic-Resistant Chalazion

For a chalazion that has not responded to a 7-day course of doxycycline, surgical incision and curettage is the recommended next step, as it offers a high success rate of approximately 90% with a single procedure.

Understanding Chalazion

A chalazion is a localized inflammatory granulomatous lesion of the eyelid that results from blockage of the meibomian gland. Unlike hordeolum (stye), which is an acute bacterial infection, a chalazion is primarily a sterile inflammatory reaction to retained sebaceous secretions.

Treatment Algorithm for Antibiotic-Resistant Chalazion

First-line options after failed antibiotic therapy:

1. Incision and Curettage (I&C)

   • Success rate: 79-90% with a single procedure 1, 2, 3
   • Advantages: Immediate removal of the lesion, tissue available for histopathology if needed
   • Disadvantages: Minor surgical procedure requiring local anesthesia, potential for scarring

2. Intralesional Triamcinolone Acetonide (TA) Injection

   • Success rate: 77-81% (may require second injection in up to 54% of cases) 1, 2, 3
   • Dosage: 4 mg (0.1-0.2 ml of 40 mg/ml solution)
   • Advantages: No surgical incision, faster recovery, better for multiple chalazia or those near lacrimal drainage system
   • Disadvantages: May require multiple injections, potential for steroid-related complications

Factors to consider when choosing between I&C and TA injection:

• Size of chalazion:

  • Medium (3-7mm) or large (>7mm): Both I&C and TA are equally effective 4
  • For suppurating granulomas in large chalazia: I&C may be superior 4

• Patient factors:

  • Multiple chalazia: Consider TA injection
  • Chalazion near lacrimal drainage system: Consider TA injection
  • Need for histopathology (recurrent, unilateral, or suspicious lesions): I&C preferred
  • Blepharitis: May require more injections if TA is chosen 1

Adjunctive Measures

While proceeding with definitive treatment, continue these supportive measures:

• Warm compresses: Apply to the affected eyelid for 10-15 minutes, 3-4 times daily
• Lid hygiene: Gentle cleansing of eyelid margins with diluted baby shampoo or commercial lid scrubs
• Topical antibiotic ointment: Consider if there are signs of secondary infection

Important Considerations

• Recurrent or persistent chalazia: Consider biopsy to rule out malignancy, especially sebaceous carcinoma 5
• Signs that warrant biopsy:
  • Marked asymmetry
  • Resistance to therapy
  • Unifocal recurrent chalazia
  • Loss of normal eyelid margin
  • Focal lash loss (ciliary madarosis) 5

Follow-up

• After I&C: Follow up in 1-2 weeks to ensure proper healing
• After TA injection: Follow up in 2-3 weeks to assess response; consider second injection if resolution is <50%

Caution

If the chalazion shows atypical features (rapid growth, unusual appearance, ulceration, or associated with eyelash loss), consider referral to an ophthalmologist for further evaluation to rule out malignancy.