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Summary Table

Category	Details
Risk Factors	Chronic blepharitis; rosacea; seborrheic dermatitis; poor lid hygiene; recurrent hordeola; immunocompromise; high androgen states
Etiology	Sterile lipogranulomatous inflammation caused by obstruction of a meibomian gland (deep) or Zeis gland (superficial) duct, with lipid extravasation into the tarsal stroma
Patient Presentation	Painless, slowly enlarging eyelid nodule present for weeks; cosmetic concern is often the chief complaint; large lesions cause blurred vision via mechanical pressure on the cornea
Classic Physical Exam	Firm, rubbery, non-tender nodule, more often on the upper lid, set back from the lid margin; overlying skin appears normal; on lid eversion the lesion "points" toward the conjunctival surface
Key Diagnostic Results	Clinical diagnosis; no labs or imaging required; histopathology is reserved for atypical or recurrent lesions and shows lipogranulomatous inflammation with multinucleated giant cells
Management	First-line: warm compresses 10 to 15 minutes, 4 times daily, with lid massage and hygiene for 4 to 6 weeks Second-line: intralesional triamcinolone Refractory or visually significant lesions: Incision and curettage via the conjunctival side
Keywords	"Painless lid lump," "rubbery nodule," "meibomian gland cyst," "points to the inner eyelid," "non-tender, non-erythematous," "rosacea-associated lid nodule"

1. Pathophysiology

A chalazion develops when a sebaceous gland of the eyelid becomes obstructed. The two glands involved are the meibomian glands, which sit deep within the tarsal plate and secrete the oily layer of the tear film, and the Zeis glands, which are smaller sebaceous glands at the base of each eyelash. When a duct is blocked, sebum cannot reach the lid margin and instead accumulates within the gland, eventually rupturing into the surrounding tarsal stroma.

The extruded lipid is recognized by the immune system as a foreign substance, triggering a chronic granulomatous inflammatory response rich in macrophages, multinucleated giant cells, and lymphocytes. This explains the cardinal feature of a chalazion on a vignette: it is firm, rubbery, painless, and slowly progressive, rather than red, warm, and tender. The lesion is sterile by definition.

Because the inflammation centers on the tarsal plate rather than the lash line, the nodule sits away from the lid margin, and the apex of the lesion typically points internally toward the palpebral conjunctiva when the lid is everted. Conditions that thicken meibomian secretions, such as rosacea, seborrheic dermatitis, and chronic blepharitis, promote ductal obstruction and explain the strong tendency for recurrence in the same patient.

A hordeolum is the acute counterpart: an obstructed gland that becomes secondarily infected, usually with Staphylococcus aureus, producing a painful red lump at the lid margin. A hordeolum can evolve into a chalazion once the bacterial infection resolves but a granulomatous residue persists. Recognizing this acute-to-chronic continuum is a high-yield concept.

2. Diagnostic Workup

Test	Role	When to Order
Inspection with lid eversion	Best initial test	Every patient; identifies the firm painless nodule and internal pointing
Slit lamp examination	Adjunct	Confirms the lesion, evaluates meibomian glands, rules out corneal indentation
Visual acuity and refraction	Functional assessment	Large or central lesions to detect induced astigmatism
Excisional biopsy with histopathology	Confirmatory and gold standard	Reserved for atypical, recurrent, ulcerating, or lash-losing lesions
Cultures	Not indicated	The lesion is sterile
Imaging	Not indicated	No role in routine evaluation

The diagnosis of chalazion is clinical. The best initial step is inspection and palpation of the eyelid with lid eversion. The examiner is looking for a firm, painless, well-defined nodule away from the lid margin, with no erythema or warmth, that "points" toward the conjunctival side when the lid is flipped. Slit lamp examination is the next step in an ophthalmology setting to evaluate the meibomian glands for chronic dysfunction and to confirm there is no corneal indentation.

Routine laboratory testing, cultures, and imaging are not part of the workup. The pivotal exception, and the favorite test point, is a recurrent chalazion in the same anatomical location, particularly in an adult older than 50, a unilateral lesion with eyelash loss (madarosis), ulceration, lid architectural distortion, or yellowish discoloration. In these scenarios, the next best step is excisional biopsy with histopathology to rule out sebaceous cell carcinoma, a malignancy that classically masquerades as a recurrent chalazion. Repeating warm compresses or another round of corticosteroid injection in this scenario is a serious management error.

When the lesion is large or central, refraction may demonstrate induced astigmatism from mechanical pressure on the cornea, which itself becomes an indication for definitive treatment.

3. Management & Treatment

Step	Treatment	Dose / Frequency / Duration
First-line (less than 4 to 6 weeks duration)	Warm compresses, lid massage, lid hygiene	Compress 10 to 15 minutes, 4 times daily; gentle massage toward the lid margin after each compress; diluted baby-shampoo lid scrubs twice daily for 4 to 6 weeks
Second-line (persists beyond 4 to 6 weeks)	Intralesional triamcinolone acetonide	0.1 to 0.2 mL of 10 to 40 mg/mL injected into the lesion; may repeat after 2 to 4 weeks
Refractory or visually significant	Incision and curettage	Trans-conjunctival approach with a chalazion clamp under local anesthesia; vertical incision parallel to gland orientation, followed by curettage
Atypical, recurrent, or suspicious	Excisional biopsy with histopathology	Mandatory to exclude sebaceous cell carcinoma
Adjunct for recurrent disease	Oral doxycycline	100 mg once daily for 6 to 12 weeks (rosacea or chronic meibomian gland dysfunction)
Pregnancy, lactation, age under 8	Oral azithromycin or erythromycin	Substitutes for doxycycline due to teratogenicity and effects on developing teeth and bone

Acute management rests on conservative therapy. Warm compresses applied for 10 to 15 minutes four times a day, combined with gentle lid massage directed toward the lid margin, soften thickened sebum and encourage drainage through the natural duct. Twice-daily lid scrubs with diluted baby shampoo address the underlying meibomian gland dysfunction. Most lesions resolve within 4 to 6 weeks under this regimen. Topical or oral antibiotics have no role in an uncomplicated chalazion because the inflammation is sterile; they are added only when there is coexistent blepharitis or a true hordeolum.

If the lesion persists beyond 4 to 6 weeks despite adherence, the next step is intralesional triamcinolone. This office-based injection is fast, avoids surgery, and is preferred for lesions near the lacrimal punctum where scarring is undesirable. The notable side effect is local skin hypopigmentation, which is more visible in patients with darker complexions and should be discussed during consent.

Lesions that fail injection, are large enough to cause mechanical ptosis, distort the cornea, or remain after several months, are treated with incision and curettage. The procedure is performed through the conjunctival side using a chalazion clamp under local anesthesia. The incision is made vertically, parallel to the orientation of the meibomian glands, to avoid cutting across multiple glands. A trans-cutaneous (skin-side) approach is avoided because of visible scarring.

For patients with recurrent chalazia driven by rosacea or chronic meibomian gland dysfunction, long-term control involves oral doxycycline 100 mg daily for 6 to 12 weeks, which works through anti-inflammatory and lipid-modulating effects rather than antimicrobial action. Doxycycline is contraindicated in pregnancy, in lactation, and in children younger than 8 because of effects on developing teeth and bone; in those groups, oral azithromycin or erythromycin is substituted.

The Next Best Step logic typically progresses as follows: confirm clinically, prescribe warm compresses for 4 to 6 weeks, escalate to corticosteroid injection if it persists, then proceed to incision and curettage if it remains. The exception that overrides this ladder is any lesion suspicious for malignancy, where the next best step is excisional biopsy regardless of duration.

4. Differential Diagnosis & Distractors

Differential Diagnosis	Why It's Similar	Key Discriminator
Hordeolum (stye)	Both are eyelid lumps from glandular obstruction	Hordeolum is acute, painful, red, warm, and points at the lid margin; chalazion is chronic, painless, and set back from the margin
Sebaceous cell carcinoma	Presents as a painless eyelid nodule, frequently mistaken for chalazion	Recurrent in the same location, older adult, lash loss (madarosis), ulceration, lid distortion, yellowish hue; biopsy mandatory
Basal cell carcinoma	Slow-growing eyelid lesion in older adults	Pearly, rolled borders with telangiectasias, typically on the lower lid margin; central ulceration ("rodent ulcer") and lash loss
Preseptal cellulitis	Eyelid swelling	Diffuse erythema, warmth, and tenderness of the entire lid, often with fever; no discrete nodule
Molluscum contagiosum	Eyelid bump	Dome-shaped, umbilicated, pearly papule, often multiple; can cause chronic follicular conjunctivitis
Pyogenic granuloma	Lid nodule, sometimes after a chalazion or surgery	Bright red, friable, vascular lesion that bleeds easily
Dermoid cyst	Lid lump in a child	Congenital, present from birth, classically at the lateral brow rather than the lid margin
Xanthelasma	Yellowish lid lesion	Soft, flat, yellow plaque on the medial canthal skin; associated with hyperlipidemia

5. Traps & High-Yield Pearls

The classic gotcha is the recurrent chalazion in an older adult. Sebaceous cell carcinoma of the eyelid is the great masquerader of chalazion, and choosing another round of warm compresses or steroid injection in a patient over 50 with a unilateral, repeatedly recurring "chalazion," lash loss, ulceration, or lid distortion is a serious miss. The correct next step is excisional biopsy with histopathology.

The second trap is reflexive antibiotic prescribing. A pure chalazion is sterile, so oral or topical antibiotics as first-line therapy are wrong. Antibiotics belong only in coexistent blepharitis, rosacea, or a true hordeolum. The third trap is sequencing: students often jump to incision and curettage at the first visit, but the expected answer for a lesion under 4 to 6 weeks old is conservative therapy. Surgery is reserved for failed conservative care or visually significant lesions.

A subtler pearl is the location of pointing: a chalazion points internally on lid eversion, whereas an external hordeolum points outward at the lash line. This single physical sign frequently steers the correct answer when the vignette is otherwise ambiguous. Remember also the contraindication of doxycycline in pregnancy, lactation, and children under 8, with substitution by a macrolide.

The core competency being tested is recognizing a chronic granulomatous lid nodule, applying a stepwise conservative-to-procedural management ladder, distinguishing it from an acute hordeolum at the lid margin, and pivoting decisively to biopsy when the clinical pattern signals an eyelid malignancy rather than benign meibomian gland obstruction.

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