What is the best management approach for a patient with a chalazion, considering potential complications and past medical history of blepharitis or rosacea?

Chalazion Management

Initial Conservative Treatment (First-Line for All Patients)

Start with warm compresses applied for 5-10 minutes, 3-4 times daily, combined with eyelid hygiene and gentle massage—this is the recommended first-line treatment for all chalazia. 1, 2

• Apply sustained warmth using hot tap water on a clean washcloth, over-the-counter heat pack, or microwaveable bean/rice bag to soften meibomian secretions 3
• Perform gentle massage of the affected area immediately after warm compresses to express the obstructed meibomian gland 1, 2
• Institute eyelid hygiene by cleaning the eyelid margins with diluted baby shampoo or commercial eyelid cleaners 3, 2
• Consider hypochlorous acid 0.01% eye cleaners for their strong antimicrobial effect 3

Critical timing consideration: Do not continue conservative management beyond 4-6 weeks without reassessment, as prolonged conservative treatment delays diagnosis of potential sebaceous carcinoma. 1, 2

Address Underlying Predisposing Conditions

Given the patient's history of blepharitis or rosacea, treating these conditions is crucial before addressing the chalazion itself, as they are common predisposing factors. 1, 2

For Blepharitis:

• Continue daily warm compresses and eyelid hygiene as maintenance therapy 3
• Consider topical antibiotics (azithromycin or erythromycin ointment) for anterior blepharitis 3
• For meibomian gland dysfunction, vertical eyelid massage to express meibomian secretions is particularly helpful 3

For Rosacea:

• Recognize that rosacea increases risk of both chalazion development and need for surgical intervention 4
• Consider systemic doxycycline for anti-inflammatory effects in severe cases 3
• Early recognition and treatment of concomitant rosacea may prevent surgical intervention 4

Escalation to Intralesional Steroid Injection

If the chalazion persists after 4-6 weeks of conservative therapy, inject triamcinolone acetonide (10 mg/mL, 0.3 mL) directly into the lesion via subcutaneous extralesional approach before considering surgery. 1, 2, 5

• This approach has a 93.8% success rate compared to 58.3% with conservative treatment alone 5
• Re-evaluate within a few weeks to assess response and check intraocular pressure 3, 2
• Potential complications include hypopigmentary skin changes at the injection site 5

Critical Red Flags Requiring Biopsy

Always biopsy chalazia that recur in the same location, especially in elderly patients, to exclude sebaceous carcinoma—this is the most critical error to avoid. 6, 1, 2

Additional indications for biopsy include:

• Marked asymmetry or resistance to standard therapy 6, 1, 2
• Atypical features: eyelid margin distortion, focal lash loss, or ulceration 6, 2
• Unilateral chronic blepharitis unresponsive to therapy 2
• Unifocal recurrent chalazia unresponsive to therapy 2

Sebaceous carcinoma may have multicentric origin with pagetoid spread and can present as chronic unilateral blepharitis or recurrent chalazia in the same location. 3

Surgical Intervention

For chalazia that fail conservative management and steroid injection, surgical incision and curettage is indicated. 7

• The subconjunctival approach offers advantages: fast, simple procedure with excellent cosmetic results 8
• Conservative treatment with hot compresses can improve meibomian gland function short-term, while surgery does not significantly affect meibomian gland function parameters 9
• Both treatment methods result in similar meibomian gland loss proportional to the original chalazion size 9

Emerging Non-Surgical Options for Recurrent Cases

Intense pulsed light (IPL) with meibomian gland expression shows promise as a non-surgical option for recurrent multiple chalazia resistant to conventional therapy. 3, 1, 2

• IPL has demonstrated high efficacy in treating moderate-to-severe blepharoconjunctivitis and can be used for recurrent multiple chalazia 3
• Use caution in individuals with darker skin pigmentation (Fitzpatrick type IV or above) due to risk of burns and pigmentation changes 1
• Low-energy IPL has been found effective and safe even in children with moderate-to-severe blepharitis 3

Special Considerations for Pediatric Patients

Children with chalazia should be evaluated for chronic blepharokeratoconjunctivitis, which is often unrecognized and may present with recurrent conjunctivitis, keratitis, neovascularization, and eyelid inflammation. 1, 2

• Refer to ophthalmology promptly if there is visual loss, moderate/severe pain, or severe/chronic redness 6, 2

Prevention Strategies for Recurrent Chalazia

• Maintain regular daily eyelid hygiene, especially in patients with blepharitis or meibomian gland dysfunction 1, 2
• Treat underlying skin conditions such as rosacea or seborrheic dermatitis 1, 2
• Avoid eye makeup during active inflammation 2
• Consider long-term maintenance with warm compresses and lid hygiene once or twice daily 3