What is the recommended treatment for a patient with a chalazion, considering potential complications and past medical history of blepharitis or compromised immune system?

Chalazion Treatment

Begin with conservative management using warm compresses and eyelid hygiene for 2-4 weeks, then escalate to intralesional steroid injection if the lesion persists, reserving incision and curettage for refractory cases. 1, 2, 3

Initial Conservative Management (First 2-4 Weeks)

Warm compresses are the cornerstone of initial treatment:

• Apply warm compresses to the affected eyelid for several minutes, once or twice daily, to soften meibomian secretions and promote drainage 1, 3
• Use hot tap water on a clean washcloth, over-the-counter heat packs, or microwaveable bean/rice bags 1
• Critical warning: Instruct patients to avoid compresses hot enough to burn the skin 1, 3

Eyelid hygiene should be performed concurrently:

• Gently massage the eyelid to express meibomian gland secretions, particularly using vertical massage techniques 1, 3
• Clean the eyelid margin using diluted baby shampoo or commercially available eyelid cleaners on a cotton swab or clean fingertip 1, 3
• Hypochlorous acid 0.01% cleaners provide strong antimicrobial effects and can be particularly useful 1, 3

Topical antibiotics may be added if there are signs of associated blepharitis:

• Apply bacitracin or erythromycin ointment to the eyelid margins once or more times daily for several weeks 1, 3
• This is especially important in patients with a history of blepharitis, as the underlying meibomian gland dysfunction predisposes to chalazion formation 1

Second-Line Treatment: Intralesional Steroid Injection

If the chalazion persists after 2-4 weeks of conservative management, intralesional steroid injection is highly effective:

• Inject 0.3 mL of triamcinolone acetonide (10 mg/mL) into the subcutaneous tissue extralesionally via the percutaneous route 4
• This approach achieves a 93.8% success rate compared to 58.3% with conservative management alone 4
• Important caveat: One potential complication is hypopigmentary skin changes at the injection site, though this is rare 4

Third-Line Treatment: Surgical Intervention

Reserve incision and curettage for chalazia that fail conservative and steroid injection therapy:

• Perform transconjunctival incision and drainage with curettage of the chalazion contents 5
• Thermal cautery after surgery does not impact recurrence rates (78% vs 74% no recurrence at 6 months with or without cautery) and should be left to practitioner discretion 5
• This approach typically achieves good surgical outcomes with recurrence rates of 22-26% at 6 months 5

Special Considerations for High-Risk Patients

Patients with compromised immune systems require closer monitoring:

• These patients may have increased risk of infection and slower resolution 1
• Consider earlier escalation to topical antibiotics and closer follow-up 1

Patients with history of blepharitis need concurrent treatment of the underlying condition:

• Continue long-term eyelid hygiene even after chalazion resolution, as blepharitis is chronic and symptoms recur when treatment is discontinued 1, 2
• Consider oral antibiotics (doxycycline for adults, erythromycin for children) if there is severe posterior blepharitis/meibomian gland dysfunction 1, 3

Patients with advanced glaucoma should be counseled carefully:

• Avoid aggressive lid pressure during warm compress application and massage, as this may increase intraocular pressure 1, 3

Critical Red Flags Requiring Biopsy

Atypical chalazia that are refractory to treatment must be biopsied to rule out malignancy:

• Consider biopsy for marked asymmetry, resistance to therapy, or unifocal recurrent chalazia 1
• Additional concerning signs include loss of normal eyelid margin anatomy, focal lash loss (ciliary madarosis), and conjunctival cicatricial changes 1
• Sebaceous cell carcinoma and cutaneous squamous cell carcinoma can masquerade as chalazion and require early intervention to prevent disfigurement and save vision 1, 6
• Before obtaining biopsy for suspected sebaceous carcinoma, consult with pathology regarding need for frozen sections, mapping of conjunctiva for pagetoid spread, and fresh tissue for oil red-O staining 1

Additional Considerations

Recurrent chalazia may indicate underlying systemic conditions:

• Subclinical hypothyroidism has been associated with recurrent chalazia, and treatment with levothyroxine may lead to remission 7
• Consider thyroid function testing in patients with multiple recurrent chalazia 7

Patient education is essential:

• Explain that chalazia are chronic inflammatory disorders related to meibomian gland dysfunction 8
• Emphasize that ongoing eyelid hygiene is necessary to prevent recurrence, as the underlying blepharitis/meibomian gland dysfunction is typically chronic 1, 2, 3
• Set realistic expectations that complete cure may not be possible and long-term management is often required 1, 2