Eyelid Swelling with Visible Cyst and Redness
The condition you're describing is most likely a chalazion (internal hordeolum) or an acute hordeolum (stye), with chalazion being more probable if there's a visible cyst-like mass under the eyelid. 1, 2
Distinguishing Between Chalazion and Hordeolum
Chalazion is a chronic, non-inflammatory lipogranulomatous cyst arising from obstruction of the meibomian glands (deep chalazion) or Zeis glands (superficial chalazion) in the tarsal plate. 2 It presents as:
- A firm, non-mobile nodular mass within the eyelid
- Localized swelling that develops gradually
- Minimal to moderate redness
- Usually painless or mildly tender 1, 2
Hordeolum (stye) is an acute purulent infection of eyelid glands, presenting with:
- Acute onset of painful, localized swelling
- More pronounced redness and inflammation
- Often associated with an eyelash follicle infection
- May have a visible pustule at the eyelid margin 3, 2
The presence of a visible cyst under the eyelid strongly suggests chalazion rather than acute hordeolum. 2, 4
Critical Red Flags Requiring Immediate Evaluation
You must exclude malignancy if any of these features are present:
- Gradual enlargement over weeks to months 5
- Hard, non-mobile mass with yellowish discoloration (suggests sebaceous carcinoma) 6
- Recurrent "chalazion" in the same location 7
- Eyelid margin destruction or loss of lashes 5
- Central ulceration, irregular borders, or telangiectasia 5
- Chronic unilateral presentation unresponsive to standard therapy for 4-6 weeks 7
Sebaceous carcinoma can masquerade as a recurrent chalazion and requires biopsy for definitive diagnosis, as it carries risk of orbital invasion and metastases. 6, 7
Initial Management Approach
For presumed benign chalazion or hordeolum:
- Warm compresses applied to the eyelid for 10-15 minutes, 3-4 times daily 1, 2
- Lid hygiene with gentle massage 1
- Observation for 4-6 weeks as many lesions drain spontaneously 7, 1
- Topical antibiotic ointment may be used, though evidence is limited 1
If the lesion persists beyond 4-6 weeks, recurs in the same location, or demonstrates any red flag features, biopsy is mandatory to exclude malignancy. 7, 4, 5
When Surgical Intervention Is Needed
Surgical options include:
- Incision and curettage for persistent chalazion 1
- Intralesional steroid injection (triamcinolone acetonide) 1
- Excisional biopsy if malignancy cannot be excluded 4, 5
Common Pitfalls to Avoid
- Never assume a recurrent eyelid lesion is benign—marked asymmetry or unifocal recurrence demands biopsy. 7
- Don't miss sebaceous carcinoma, which often has a history of multiple chalazion excisions and can present with chronic unresponsive blepharoconjunctivitis. 6
- Avoid prolonged conservative management beyond 6 weeks without reassessment for atypical features. 7, 4