What is the initial management for a patient presenting with a chalazion?

Initial Management of Chalazion

Start with warm compresses applied for 5-10 minutes, 3-4 times daily, combined with eyelid hygiene and gentle massage as first-line therapy for all chalazia. 1

Conservative Management Protocol

The American Academy of Ophthalmology recommends this stepwise approach for initial treatment:

• Apply warm compresses to the affected eyelid for 5-10 minutes, 3-4 times daily, to promote drainage of the obstructed meibomian gland 1
• Perform gentle massage of the affected area immediately after warm compresses to help express the obstructed gland 1
• Institute eyelid hygiene by cleaning the eyelid margins with mild soap or commercial eyelid cleansers 1

This conservative approach is supported by clinical trial data, though the evidence base remains relatively weak and based primarily on expert consensus 2. However, conservative management alone shows only a 46% resolution rate at 3 weeks compared to more aggressive interventions 3.

Treatment Timeline and Escalation

Do not continue conservative management beyond 4-6 weeks without reassessment, as prolonged conservative therapy delays diagnosis of potential malignancy 1, 4. This is a critical pitfall to avoid.

If the chalazion persists after 4-6 weeks of conservative therapy:

• Inject triamcinolone acetonide directly into the lesion as the next step before considering surgery 1
• Intralesional steroid injection achieves a 93.8% success rate compared to 58.3% with conservative management alone 1
• This approach shows an 84% resolution rate at 3 weeks with significantly less pain and inconvenience than surgical treatment 3
• Re-evaluate within a few weeks to assess response and check intraocular pressure after intralesional steroid injection 1

Common pitfall: Hypopigmentary skin changes can occur at the injection site with intralesional steroids 1.

Address Underlying Conditions First

Before treating the chalazion itself, evaluate and treat predisposing factors:

• Treat any associated bacterial blepharitis or meibomian gland dysfunction before addressing the chalazion, as these are common predisposing factors 1, 4
• Evaluate for meibomian gland dysfunction, rosacea, or seborrheic dermatitis in patients with recurrent chalazia 1, 5
• Consider systemic antibiotics for severe underlying blepharitis 1

In rare cases, subclinical hypothyroidism may predispose to recurrent chalazia and should be considered in patients with persistent recurrence 6.

Critical Red Flags Requiring Biopsy

Always biopsy chalazia with any of these features to exclude sebaceous carcinoma:

• Recurrence in the same location, especially in elderly patients 1, 4, 5
• Marked asymmetry or resistance to standard therapy 1, 4
• Unifocal recurrent chalazia unresponsive to therapy 1, 4
• Atypical features including eyelid margin distortion, focal lash loss, or ulceration 1, 4
• Unilateral chronic blepharitis unresponsive to therapy 1, 4, 5
• History of multiple chalazion excisions at the same site 5

Sebaceous carcinoma can masquerade as a chalazion, and delayed diagnosis significantly impacts morbidity and mortality 5.

Pediatric Considerations

• Evaluate children with chalazia for chronic blepharokeratoconjunctivitis, which is often unrecognized and may present with recurrent conjunctivitis, keratitis, neovascularization, and eyelid inflammation 1, 4, 5
• Refer to ophthalmology if there is visual loss, moderate/severe pain, or severe/chronic redness 1
• Intralesional steroid injection may be particularly suitable for children who have allergy to local anesthetics or fear of surgery 7