What is the diagnosis and next steps for a 20-year-old male with a gradually enlarging, fleshy, soft mass on the left lower eyelid, sparing the eyelash line and conjunctiva, with a history of a similar episode that temporarily resolved with mefenamic acid and a topical antibiotic, and currently has normal visual acuity (VA) of 20/20 in both eyes (OU)?

Diagnosis: Chalazion (Meibomian Gland Cyst)

The most likely diagnosis is a chalazion—a chronic, sterile, granulomatous inflammation of the meibomian gland presenting as a fleshy, soft, immovable mass on the lower eyelid that spares the eyelash line and conjunctiva. 1

Clinical Reasoning

Key Diagnostic Features Supporting Chalazion

• Location and characteristics: The fleshy, soft, immovable mass on the lower eyelid that spares the eyelash line is classic for chalazion, which arises from meibomian glands located within the tarsal plate 1

• Recurrent history: The patient's history of a similar episode 4 months prior that temporarily resolved is typical of chalazia, which commonly recur and are associated with chronic blepharitis and meibomian gland dysfunction 1

• Gradual enlargement: The progressive growth over one week from a small lesion to current size is consistent with the natural history of chalazion formation 1

• Age and presentation: While chalazia can occur at any age, the unilateral presentation in a young adult without systemic symptoms fits the typical pattern 1

Critical Red Flags to Exclude (All Absent in This Case)

You must actively rule out malignancy, particularly sebaceous carcinoma, which can masquerade as recurrent chalazia. 1 Warning signs include:

• Unifocal recurrent lesions in the exact same location that don't respond to standard therapy 1
• Focal lash loss (ciliary madarosis) 1
• Loss of normal eyelid margin architecture 1
• Marked asymmetry or resistance to therapy 1
• Chronic unilateral presentation unresponsive to treatment, especially in elderly patients 1, 2

This patient's lesion appears to be in a different location than the prior episode (not unifocal recurrent), has no lash loss, and shows normal eyelid margin anatomy—making malignancy unlikely. 1

Next Steps: Management Algorithm

Initial Conservative Management (First-Line)

1. Warm compresses: Apply for 10-15 minutes, 3-4 times daily to promote meibomian gland drainage 1

2. Eyelid hygiene: Gentle massage of the eyelid margin after warm compresses to express meibomian gland contents 1

3. Observation period: Most chalazia resolve spontaneously within 2-4 weeks with conservative management 1

If No Improvement After 4-6 Weeks

1. Intralesional corticosteroid injection: Triamcinolone acetonide (0.1-0.2 mL of 40 mg/mL) injected directly into the lesion can accelerate resolution 3

2. Incision and curettage: Surgical drainage through the conjunctival approach (preferred to avoid external scarring) if conservative measures and injection fail 3

When to Biopsy (Critical Decision Point)

Obtain a biopsy if any of the following occur: 1

• The lesion recurs in the exact same location after treatment 1
• No response to standard therapy after 6-8 weeks 1
• Development of focal lash loss or eyelid margin distortion 1
• Any suspicion of malignancy based on atypical features 1

Before obtaining a biopsy for suspected sebaceous carcinoma, consult with pathology regarding the need for frozen sections and mapping for pagetoid spread, as fresh tissue may be needed for special stains like oil red-O. 1

Address Underlying Meibomian Gland Dysfunction

Since this patient has recurrent episodes, evaluate for chronic blepharitis and meibomian gland dysfunction: 1

• Examine meibomian gland orifices for capping, pouting, or obstruction 1
• Assess meibomian secretions by applying pressure to the lower eyelid—look for thick, turbid, or toothpaste-like secretions rather than clear oil 1
• Long-term eyelid hygiene and warm compresses to prevent recurrence 1
• Consider omega-3 fatty acid supplementation and treatment of any associated skin conditions like rosacea 1

Common Pitfalls to Avoid

• Don't dismiss recurrent lesions as "just another chalazion" without careful examination for malignancy warning signs 1
• Don't delay biopsy in elderly patients with atypical or recurrent lesions, as sebaceous carcinoma has high metastatic potential 1
• Don't forget to examine the contralateral eye and perform slit-lamp biomicroscopy to assess for bilateral meibomian gland dysfunction 1
• Don't prescribe systemic antibiotics (like the mefenamic acid given previously)—chalazia are sterile inflammatory lesions, not infections 1