What is the recommended management for a chalazion?

Chalazion Management

Start with warm compresses (5-10 minutes, 3-4 times daily) combined with eyelid hygiene as first-line therapy for all chalazia, and escalate to intralesional triamcinolone injection if there is no resolution after 4-6 weeks of conservative management. 1, 2

Initial Conservative Management (First 4-6 Weeks)

• Apply warm compresses to the affected eyelid for 5-10 minutes, 3-4 times daily, to promote drainage of the obstructed meibomian gland 1, 2
• Perform gentle massage of the affected area immediately after warm compresses to help express the obstructed gland 1, 2
• Institute eyelid hygiene by cleaning the eyelid margins with mild soap or commercial eyelid cleansers 1, 2
• Treat any associated bacterial blepharitis or meibomian gland dysfunction before addressing the chalazion itself, as these are common predisposing factors 1, 2

Treatment Escalation After 4-6 Weeks

Do not continue conservative management beyond 4-6 weeks without reassessment, as this delays diagnosis of potential malignancy—the most critical error in chalazion management. 1, 2

• Inject triamcinolone acetonide directly into the lesion as the next step before surgery for persistent chalazia after 4-6 weeks of conservative therapy 1, 2
• This achieves a 93.8% success rate compared to 58.3% with conservative management alone 1
• Re-evaluate within a few weeks to assess response and check intraocular pressure after intralesional steroid injection 1
• Be aware that hypopigmentary skin changes at the injection site are a common pitfall 1

Critical Red Flags Requiring Biopsy

Always biopsy recurrent chalazia in the same location, especially in elderly patients, to exclude sebaceous carcinoma. 1, 2, 3

• Biopsy chalazia with marked asymmetry or resistance to standard therapy 1, 2
• Biopsy unifocal recurrent chalazia unresponsive to therapy 1
• Biopsy chalazia with atypical features including eyelid margin distortion, focal lash loss (madarosis), or ulceration 1, 3
• Biopsy unilateral chronic blepharitis unresponsive to therapy 1, 3
• History of multiple chalazion excisions at the same site should prompt biopsy 3

Addressing Underlying Conditions for Recurrent Chalazia

• Evaluate for meibomian gland dysfunction, rosacea, or seborrheic dermatitis in patients with recurrent chalazia 1, 2, 3
• Institute regular eyelid hygiene for patients with blepharitis 1, 2
• Consider systemic antibiotics for severe underlying blepharitis 1
• Treat underlying skin conditions such as rosacea or seborrheic dermatitis to prevent recurrent chalazia 1, 2, 3
• Consider evaluating for subclinical hypothyroidism in patients with recurrent chalazia refractory to standard management 4

Emerging Non-Surgical Options for Refractory Cases

• Intense pulsed light (IPL) with meibomian gland expression shows promise as a non-surgical option for recurrent multiple chalazia resistant to conventional therapy, with high Demodex eradication rates and improved meibum quality 1, 2
• Use IPL with caution in darkly pigmented individuals (above Fitzpatrick skin type IV) due to risk of burns and pigmentation changes 1, 2
• Vectored thermal pulsation therapy may improve meibomian gland function 1

Pediatric Considerations

• Children with chalazia should be evaluated for chronic blepharokeratoconjunctivitis, which is often unrecognized and may present with recurrent conjunctivitis, keratitis, neovascularization, and eyelid inflammation 1, 2, 3
• Refer to ophthalmology if there is visual loss, moderate/severe pain, or severe/chronic redness in children with chalazia 1, 3

Prevention Strategies

• Maintain regular eyelid hygiene for patients prone to recurrent chalazia, especially those with blepharitis or meibomian gland dysfunction 1, 2, 3
• Avoid eye makeup during active inflammation 1, 3

Common Pitfalls to Avoid

The most critical error is prolonging conservative management beyond 4-6 weeks without reevaluation, which may delay the diagnosis of sebaceous carcinoma, particularly in older patients with unilateral or recurrent lesions. 1, 2

• Do not dismiss recurrent lesions in the same location as benign without biopsy 1, 2
• Do not overlook moderate to severe pain, as this may indicate an acute hordeolum, secondary infection, or atypical presentation requiring immediate ophthalmologic evaluation 3