What is the recommended treatment for a patient with a chalazion, considering potential complications and past medical history of blepharitis or other eyelid conditions?

Treatment for Chalazion

Initial Conservative Management (First-Line)

Begin with warm compresses applied to the affected eyelid for several minutes, once or twice daily, combined with eyelid hygiene and gentle massage to express meibomian gland secretions. 1

Warm Compress Technique

• Use hot tap water on a clean washcloth, over-the-counter heat packs, or microwaveable bean/rice bags 1
• Apply for several minutes once or twice daily to soften meibomian secretions and promote drainage 1
• Critical caveat: Instruct patients to avoid compresses hot enough to burn the skin 1
• Patients with advanced glaucoma should avoid aggressive lid pressure during application, as this may increase intraocular pressure 1, 2

Eyelid Hygiene Protocol

• Gently massage the eyelid to express meibomian gland secretions 1
• Clean the eyelid margin using diluted baby shampoo or commercially available eyelid cleaners 1
• Hypochlorous acid 0.01% cleaners provide strong antimicrobial effects and are particularly useful 1, 2

When to Add Topical Antibiotics

• Add topical antibiotics (bacitracin or erythromycin ointment) if there are signs of associated blepharitis 1
• Patients with a history of blepharitis require concurrent treatment of the underlying condition and should receive topical antibiotics as part of initial therapy 1

Duration and Expectations

• Conservative therapy is effective for chalazia present less than 2 months 3
• Lesions present for more than 2 months are significantly less likely to resolve with conservative therapy alone (p = .04) 3
• Complete resolution with conservative therapy occurs in approximately 18-21% of cases after 4-6 weeks 3

Second-Line Treatment: Intralesional Steroid Injection

For chalazia that fail to resolve after 2-4 weeks of conservative management, or for lesions present longer than 2 months, proceed directly to intralesional triamcinolone acetonide injection. 1, 3

Injection Technique and Efficacy

• Inject 0.2-0.3 mL of triamcinolone acetonide (10 mg/mL) into the lesion 4, 5
• Resolution rate is 84-94% with a single injection 4, 5
• Significantly more effective than conservative treatment (93.8% vs 58.3%, p < 0.001) 5
• Causes less pain and patient inconvenience compared to surgical treatment, with similar efficacy (84% vs 87%) 4
• Patient satisfaction is equivalent to surgical treatment but superior to conservative management 4

Potential Complications

• Hypopigmentary skin changes can occur at the injection site 5
• Monitor for skin atrophy 5

Third-Line Treatment: Incision and Curettage

Reserve surgical excision for chalazia that fail steroid injection or for patients who prefer definitive treatment. 4

Surgical Considerations

• Resolution rate is 87% 4
• Higher pain scores compared to steroid injection (p < 0.003) 4
• Greater patient inconvenience compared to injection therapy 4
• Patient satisfaction equivalent to steroid injection 4

Special Population Considerations

Patients with History of Blepharitis

• Require concurrent long-term treatment of underlying blepharitis with eyelid hygiene 1, 2
• Consider oral antibiotics (doxycycline, minocycline) if severe posterior blepharitis/meibomian gland dysfunction is present 2
• Topical antibiotics should be included in initial conservative management 1

Immunocompromised Patients

• Require closer monitoring due to increased infection risk and slower resolution 1
• Benefit from earlier escalation to topical antibiotics 1

Patients with Advanced Glaucoma

• Counsel carefully to avoid aggressive lid pressure during warm compress application and massage 1, 2

Critical Red Flags Requiring Biopsy

Atypical chalazia that are refractory to treatment must be biopsied to rule out malignancy. 1

Concerning Features

• Marked asymmetry 1
• Resistance to therapy 1
• Unifocal recurrent chalazia 1
• Loss of normal eyelid margin anatomy 1
• Focal lash loss 1
• Conjunctival cicatricial changes (may indicate sebaceous cell carcinoma or cutaneous squamous cell carcinoma) 1

Patient Education

• Explain that chalazia are chronic inflammatory disorders related to meibomian gland dysfunction 1
• Emphasize the importance of ongoing eyelid hygiene to prevent recurrence 1
• Set realistic expectations: complete cure may not be possible and long-term management is often required 1
• For recurrent cases, consider evaluation for underlying conditions such as subclinical hypothyroidism 6

Treatment Algorithm Summary

1. Start with warm compresses + eyelid hygiene for 2-4 weeks (add topical antibiotics if blepharitis present) 1, 3
2. If no resolution after 2-4 weeks OR lesion present >2 months: proceed to intralesional triamcinolone acetonide injection 4, 3
3. If injection fails: perform incision and curettage 4
4. If recurrent or atypical features: biopsy to rule out malignancy 1