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CHALAZION

Anatomy

Meibomian glands are the oil-producing glands located in both the upper and lower eyelids. They number about 25 to 30 (each: a total of about 100) and normally slowly release oil into the tear film. ***This oil helps to stop the water in the tears from evaporating, thus helping to prevent dry eyes. The Meibomian glands of the tarsal plate produce the lipid that will line the layer of the tear film. The Meibomian lids empty into ducts that dot the marginal surface of the eyelid and can be seen emanating droplets of oil for the tears.  (http://eyestrain.sabhlokcity.com/2011/09/meibomian-gland-disease-mgd/)

Definition

A chalazion (Greek for hailstone) is a non-infectious inflammation of the Meibomian glands or Zeis glands (as vs. Stye which is an infection of a sweat-gland or hair follicle, similar to a pimple).

A chalazion is a term used by the medical profession to denote a swelling caused by blockage of sebaceous glands and formation of granulomas in the sebaceous Meibomian oand/or Zeis glands. (http://www.pediatriceducation.org/2010/07/05/whats-the-difference-between-a-stye-hordeolum-and-chalazion/)

Incidence (Medscape.com)

Chalazia are common but the incidence or prevalence are unknown or unavailable (for US or worldwide) It is more common in adults than children, exacerbated by the presence of hormones which increase the

viscosity of sebum. Hormonal influences may explain the clustering of incidences at the time of puberty or pregnancy

Etiology (Medscape)

1. Chalazia may arise spontaneously due to blockage of a gland orifice or due to an internal hordeolum. Chalazia are associated with seborrhea, chronic blepharitis, and acne rosacea.

2. Poor lid hygiene is occasionally associated with chalazia, although its causal role needs to be established. 3. Although stress is often apparently associated with chalazia, it has not been proven as a cause, and the

mechanism by which stress acts is unknown.

2Pathophysiology

Also called a Meibomian cyst, tarsal cyst or a conjunctival granuloma, the inflammation is caused when the ducts of the Meibomian gland that lubricates the eye gets clogged and because passage is impossible, oil builds up inside the gland causing inflammation. Because this is not a bacterial infection, the lump simply hardens over time and causes pain only when it has grown large enough to affect the endings of the sensory nerve. In worst case scenarios, the chalazion can impinge the cornea and cause vision problems.

Clinical Manifestations/Signs & Symptoms

Chalazia appear as large, unsightly lumps deep w/in the eyelid, and are usually not painful

It is a small, slow growing, hard but painless nodule on the lid. The skin moves freely over it There is an absence of inflammation or edema It is characterized generally by a single nodule (Though in rare cases there may be multiple) (Medscape) Swelling on the eyelid Eyelid tenderness Increased sensitivity to light Excessive tearing (Epiphora) Heaviness of eyelid Eye fatigue Generally is unilateral

Diagnostic Evaluation (Medscape)

Subjective Data: History 1. Patients with chalazia usually present with a short history of recent lid discomfort, followed by acute

inflammation (eg, redness, tenderness, swelling). 2. They frequently have a long history of previous similar occurrences, because chalazia tend to recur in

predisposed individuals.

Objective Data: Physical Examination: 1. Dx is confirmed upon physical examination 2. Chalazia are more common on the upper lid than on the lower lid because of the increased number and length

of Meibomian glands present on the upper lid.3. Examination of the eye may be necessary with a Slit Lamp in order to view the Meibomian glands – access

the eyelid by inverting it with a Q-tip4. Biopsy of the lump – done only if skin cancer is suspect.

Complications

1. Chalazia can become quite large and put pressure on the cornea and thereby cause visual changes.

2. (http://www.pediatriceducation.org/2010/07/05/whats-the-difference-between-a-stye-hordeolum-and-chalazion/)

3. Dysfunctional Meibomian glands often cause dry eyes, one of the more common eye conditions. They may also cause blepharitis, as the dry eyeball rubs off small pieces of skin from the eyelid, which may get infected. (Wikipedia)

4. Recurring chalazia in the same area may sometimes be a symptom of sebaceous cell carcinoma – in rare cases

Pillitteri

Wikipedia

3Medical Management

None – if it is self-resolving Warm compresses applied three to four times a day for 10–15 minutes may resolve the inflammation in the

early stages, to facilitate drainage of the oil and thus reduce the swelling. It is also recommended that the area around the chalazion be lightly massaged several times during the day as

well. An important thing to remember when doing a chalazion home treatment is to not pop the chalazion like you

would a pimple. Nor should you scratch it. Doing either of these can cause further complications.

Medications: 1. Corticosteroid injection as to the chalazion lesion may be used for smaller lesions. 2. Topical steroids – Prednisone acetate (Ocupred) Dexamethasone (Dexair), Betamethasone (bethnesol) (,…

Fluor-Op) 3. Antibiotics are Chloramphenicol, Fusidic acid4. There may be a need for prophylactic antibiotics w. macrolide antibiotics such as erythromycin ointments or

azithromycin

Surgical Intervention: 1. Incision and curettage is the surgery of choice by physicians. 2. The procedure is usually done as an outpatient or day-case at the hospital. 3. May take about 20minutes. 4. Surgeon turns eyelid out and makes the small incision between two clamps into the gland and the contents are

removed. 5. The eyelid may be swollen and bruised for up to 1 week post-surgery. 6. If a hematoma occurs 3-4days occurs postsurgery do a biopsy to rule out cancer7. Pressure patch for 6-8 hours 8. Non-pressure patch as 4-6 hours post surgery. 9. Warm compress after removal of patch10. Instillation of eye drops

The surgical procedure which is done to remove the chalazion is usually performed under local anesthetic. A pressure eye patch is applied for about 24 hours after the surgical procedure to manage bleeding and swelling. Once the patch is removed, warm compresses are also applied to further bring down the swelling. Antimicrobial eye drops are usually prescribed to prevent secondary infections, and painkiller medication is usually given to allow the patient to cope with minor discomforts after the operation.

Nursing Assessment

Dx of chalazion is clinical, however during the 1st 2 days the chalazion and the stye may be indistinguishable

If the chalazion lies near the inner cantus of the lower eyelid, it must be differentiated from dacryocystitis (inflammation of the lacrimal gland); which can usually be excluded by noting the location of maximum induration (hardness around the point of inflammation) and tenderness.

Chalazion form on the eyelid but under the medial canthus near the side of the nose for dacryocystitis

How does chalazion differ from stye in appearance?

4Nursing Diagnosis and Expected Outcome

Body Image Disturbance related to lesion/growth on the eye as aeb by patients verbalization of the same

Family Education and Health Maintenance – Discharge Planning

Although a stye is a lump in the eye lid caused by obstruction of the oil gland, a chalazion is not a stye. A stye (hordeolum) represents an acute infection of the gland

Inflammation is a process in which the body reacts to a condition and produces swelling, redness, pain or warmth. A stye is usually more painful than an chalazion, and may have purulent exudates

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Incision and Curettage of a Chalazion

By definition, chalazion is an enlarged meibomian gland with an obstructed orifice, and containing retained secretory products secondary to chronic inflammation. These usually present as a painless and firm swelling [Figure 1].  Initial treatment for a chalazion in the acute stage is hot compresses for 10-12 minutes daily for a few days, followed in most cases by drainage of the retained material through the gland orifice. However, in chronic cases, the chalazion does not respond to this conservative treatment and must be incised and curetted.

The following steps demonstrate incision and curettage of a chalazion:

Step 1:  After prepping the skin, inject a small volume of Xylocaine with Adrenaline (1:100,000) mixture locally [Figure 2]. Adrenaline minimizes post-operative bleeding. 

Local anesthetic is injected subcutaneously over the mass.

Step 2:  Localize the lesion on the conjunctival surface before a chalazion clamp of appropriate size is placed [Figure 3].

The chalazion appears as a slightly red, raised lesion on the conjunctival surface of the tarsus.

Step 3:  Evert the lid and make sure that the lesion is well centered within the clamp so that the chalazion mass is centered in the open ring of the clamp on the conjunctival surface [Figure 4].

The chalazion clamp is placed with the conjunctival surface of the chalazion centered in the ring of the clamp.

Step 4:  A vertical incision is made with Bard Parker blade No.15.  The reason for the vertical cut being that the Meibomian glands are placed vertically meaning that the vertical cut would not damage the adjacent normal Meibomian glands [Figure 5].

Take care that the incision does not extend within 2 mm of lid margin to prevent post-operative lid margin distortion

Using a No. 15 Bard Parker blade a vertical cut is made over the "lump" in the center of the ring to gain access to the clogged Meibomian gland.

Step 5:  Thick chalazion contents will pour out immediately as the incision is placed at the correct site and correct depth of the mass [Figure 6].

As soon as the blade enters the chalazion, the viscous content spills out.

Typical appearance of a chalazion at the outer aspect of the right upper lid

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Step 6:  Then scoop out the contents of the chalazion with the help of largest sized curette possible [Figure 7].

A curette is used to scoop out the contents.

Step 7:  Once assured that cyst has been thoroughly emptied of its contents, remove the clamp [Figure 8]. As the hemostat effect of clamp is gone, it would start bleeding, which should not be of much concern [Figure 9]. Pressure-patch the eye well with antibiotic ointment for few hours. Prescribe the antibiotics ointment twice for 3-5 days.

Figure 8 - click picture to enlargeA cotton tip applicator can be used to wipeaway the viscous material ensuring that theinflammatory debris is removed completely.

Figure 9 - click picture to enlargeWhen the clamp is removed Hemostasis is lostand the lid will bleed.  Place antibiotic ointmentin the cul-de-sac and patch the eye with pressure.

In most cases the site will heal completely and the process is complete unless, or until, another chalazion occurs.  Chalazia are usually sporadic and isolated occurrences.  However, in rare instances individuals suffer from multiple, repeated chalazia that require multiple treatments with excision and in some cases prophylactic antibiotics, usually tetracyclines.  Recurrent chalazia should be biopsied to rule out Meibomian gland carcinoma.

Dr. Ekta Aggarwal