What is the cause and treatment of a small hard bulge at the upper eyelid in an adult with no significant medical history?

Small Hard Bulge at Upper Eyelid

The most likely diagnosis is a chalazion, which should be treated initially with warm compresses for 5-10 minutes once or twice daily plus gentle eyelid cleansing, with referral to ophthalmology if the lesion persists beyond 4-6 weeks or if there are any concerning features suggesting malignancy. 1, 2

Immediate Red Flag Assessment

Before proceeding with conservative management, you must rule out serious conditions:

• Examine for orbital cellulitis signs: proptosis, restricted or painful extraocular movements, decreased visual acuity, severe pain with eye movement, fever with systemic toxicity 3, 1, 2
• If any red flags present: hospitalize immediately for IV antibiotics, obtain contrast-enhanced CT of orbits/sinuses, and consult ophthalmology urgently 3, 2
• Check visual acuity, extraocular movements, pupillary response, and evert the upper eyelid to examine tarsal conjunctiva 1

Most Likely Diagnosis: Chalazion

A chalazion is the most common cause of a small, hard, non-tender nodule on the upper eyelid in adults:

• Chalazion develops from retained secretions of meibomian or Zeis glands, presenting as a firm, non-inflammatory mass within the tarsal plate 4, 5
• The lesion is typically painless, localized, and moves with the eyelid 6
• It may cause mild ptosis if large enough 7

First-Line Treatment Approach

Conservative management should be attempted for 4-6 weeks before considering other interventions:

• Apply warm compresses for 5-10 minutes once or twice daily to help liquefy retained secretions 1, 2
• Perform gentle eyelid cleansing with diluted baby shampoo or hypochlorous acid 0.01% after compresses 1, 2
• Gentle massage may help express gland contents 2
• Consider topical antibiotic ointment (bacitracin or erythromycin) applied to lid margins at bedtime if there are signs of secondary infection 2

When to Refer to Ophthalmology

Refer for ophthalmology evaluation if:

• Chalazion persists after 4-6 weeks of conservative management 1, 2
• Recurrent chalazia or hordeola 1
• Any concerning features for malignancy: unifocal recurrent lesions, resistance to therapy, focal lash loss, chronic unilateral presentation unresponsive to treatment 3

Critical Malignancy Warning Signs

Sebaceous carcinoma can masquerade as a chronic chalazion and must be considered in certain scenarios:

• Biopsy is indicated for: unifocal recurrent lesions, resistance to standard therapy, focal lash loss, chronic unilateral presentation unresponsive to treatment, or any hard nodular mass with yellowish discoloration 8, 3
• Sebaceous carcinoma typically occurs in the fifth to ninth decades of life and may have a history of multiple chalazion excisions 8
• Never delay biopsy if malignancy is suspected, as sebaceous carcinoma can metastasize regionally or distantly 8

Important Clinical Pitfalls

• Never start topical corticosteroids before ruling out infection, as this may worsen infectious processes or mask accurate diagnosis 1, 2
• Patients with advanced glaucoma should avoid aggressive eyelid pressure during warm compress application to prevent intraocular pressure elevation 1
• Do not assume all eyelid masses are benign chalazia—maintain high suspicion for malignancy in recurrent or treatment-resistant cases 3

Follow-Up Timeline

• Reassess in 2-4 weeks if symptoms persist despite conservative management 1
• If no improvement after 4-6 weeks, refer to ophthalmology for possible intralesional steroid injection or surgical excision 1, 4