CALAZION AND HORDEOLUM

A. Definition

Hordeolum is an infection of one or more glands in the eyelids. When the

meibomian glands are affected it is known as an internal hordeolum.

Hordelum externa or commonly called "stye" is an infection of the glands of

Zeis or Moll. External hordeolum is often mistaken for a chalazion.5,6

Chalazion is a chronic, focal and sterile inflammation of the eyelids caused

by obstruction of the meibomian glands. Chalazion is also often referred to as

chronic sterile lipogranuloma. Deep chalazion is caused by inflammation of

the tarsal meibomian glands and superficial chalazion is caused by

inflammation of the glands of Zeis. Kalazia is the plural form of chalazion.

Chalazion is a benign and self-limiting condition although it can develop into

chronic complications. Recurrent chalazion needs further examination to

exclude the possibility of malignancy.5,7

B. Epidemiology

Hordeolum is a condition that often occurs and often patients do not go to

health services to check themselves. There is no direct correlation between

race, sex, or gender with regard to the prevalence of hordeolum. Adults may

be more susceptible due to increased sebum viscosity. Patients with conditions

such as blepharitis, seborrheic dermatitis, rosacea, diabetes, and

hypercholesterolemia are also at increased risk of developing hordeolum.6

Chalazion is a common condition, although the exact number of

occurrences either in the US or worldwide is not documented. Chalazion

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 appears to affect men and women equally, but exact numbers are not

available. Chalazion is more common in adults (age 30-50).7

C. Etiology

The most common causative organism is Staphylococcus aureus. Bacterial

infections typically develop near the roots (follicles) of the eyelashes. A

person can experience more than one hordeolum at the same time or several

times in a row.

Several predisposing factors that can cause hordeolum and chalazion:8,9

1. Age. Hordeolum and chalazion are more common in children and young

adults (although there is no age limit). Patients with eye strain resulting

from muscle imbalance or refractive errors.

2. Hygiene. Hordeolum is not contagious, but can arise from poor hygiene

habits such as rubbing the eyes or holding the eyelids. Hordelum can also

occur if a person uses expired cosmetics or leaves eye makeup overnight.

Contact lens wearers can develop hordeolum if they don't wash their hands

thoroughly and disinfect their contact lenses before wearing them.

3. Chronic blepharitis can also cause hordeolum formation. Treatment of

chronic blepharitis can help prevent relapses.

4. Diabetes mellitus is usually associated with recurrences.

5. Metabolic factors such as chronic disease, eating a diet high in

carbohydrates and alcohol are also predisposing factors.

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D. Pathophysiology

Three different glands within the eyelid are involved in the pathogenesis

of hordeolum when they are infected. Infection occurs due to thickening or

stasis of gland secretions of Zeis, Moll, or Meibom. The glands of Zeis and

Moll are the ciliary glands of the eye. Zeis glands secrete sebum with

antiseptic properties that can prevent bacterial growth. Moll glands produce

immunoglobulin A, mucin 1, and lysosomes which are important in immune

defense against bacteria in the eye. The meibomian glands are sebaceous

glands found on the tarsal plates of the eyelids and produce a secretion that

forms an oily film on the surface of the eye that helps maintain eye

lubrication.6,10

When this gland is clogged it will cause the eye's defense to be disrupted.

Staphylococcus aureus is the etiology of bacterial infection because

Staphylococcus aureus is the most common pathogen. After a local

inflammatory response occurs, infiltration by leukocytes develops into a

purulent pocket or abscess. Infection of the glands of Zeis and Moll (ciliary

glands) causes pain and swelling at the base of the eyelashes with localized

abscess formation. The external hordeolum produces the characteristic stye

appearance with localized pustules at the eyelid margin. When the meibomian

glands are acutely infected they will produce an internal hordeolum. Due to its

deeper position within the eyelid, the internal hordeolum has a less

pronounced appearance than the external hordeolum.6,10

Chalazion occurs secondary to mechanical obstruction and dysfunction of

the meibomian glands, followed by stasis and blockage of sebum release. This

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 condition tends to be subacute to chronic and presents as painless nodules

within the eyelid or on the eyelid margin.10A chalazion is an inflammatory

lesion that forms when the products of lipid breakdown leak into the

surrounding tissue and trigger a granulomatous inflammatory response. For

this reason, chalazion is also called conjunctival granuloma. Meibomian

glands are embedded in the tarsal plate of the eyelids; therefore, edema due to

blockage of this gland is usually found in the conjunctiva of the eyelids.

Occasionally, the chalazion may enlarge and penetrate the tarsal plate to the

outside of the eyelid. Chalazion due to blockage of the gland of Zeis is usually

located along the edge of the eyelid.7

E. Diagnosis

In diagnosing hordeolum and chalazion, the symptoms and signs that

appear in the patient must be considered. Symptoms and signs seen from the

history and physical examination. In diagnosing hordeolum or chalazion,

additional investigations are not needed because the diagnosis is made

clinically or based on clinical manifestations. Additional examinations and

radiology are usually performed if complications occur and the infection has

spread and caused periorbital or orbital cellulitis. For example, in internal

hordeolum which can cause corneal irritation where fluorescence examination

can be carried out.8

Clinical manifestations of hordeolum and kalazion are as follows:

1. External hordeolum8,11

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 - Symptoms: Acute pain is usually accompanied by swelling of the lids,

mild lacrimation and photophobia. The external hordeolum usually

looks like a lump protruding anteriorly through the skin with the

eyelashes at the apex.

- Sign :

a. The cellulitis stage is characterized by a tender, hyperemic, hard

swelling localized to the palpebral margin.

b. The abscess formation stage is characterized by a tip of pus at the

palpebral margin in contact with the infected cilia.

In the external hordeolum multiple lesions may appear and

occasionally an abscess may involve the entire lid margin.

Figure 1. Upper lid external hordeolum

2. Internal hordeolum8

- Symptoms: acute pain accompanied by swelling of the lids, mild

lacrimation and photophobia. The symptoms are very similar to those

of an external hordeolum except that the pain is felt more intensely due

to the swelling within the dense connective tissue.

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 - Signs: Localized swelling of the lids, firm boundaries, hyperemia and

has tenderness accompanied by edema with firm boundaries. On

examination, the internal hordeolum can be distinguished from the

external because the center of tenderness and swelling is far from the

palpebral margin and the punctum is usually on the tarsal conjunctiva,

not on the ciliary roots. Often, a punctum will be seen at the opening of

an infected meibomian gland or on the skin but rarely.

Figure 2. Internal hordeolum on the inferior lid

3. Kalazion8,11

- Symptom :

a. Painless swelling of the lids, which usually increases in size

gradually, is the patient's chief complaint.

b. Feels heavy on the lids in moderate to large chalazion.

c. Blurred vision due to astigmatism which can occur in patients with

very large chalazions pressing on the cornea.

d. Epiphora may result from eversion of the punctum resulting from a

large chalazion on the inferior lid.

- Sign :

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 a. The nodule is usually at some distance from the palpebral margin

where it is firm and not painful on palpation. Chalazia are usually

more common on the superior lid than the inferior lid. Multiple

chalazia may occur.

b. A purplish-red area at the site of the chalazion can usually be seen

on the palpebral conjunctiva after eversion of the lids.

c. Swelling projections on the skin side can appear although rarely

because they are more often towards the conjunctiva

d. A marginal chalazion usually appears as a characteristic small red-

gray nodule at the lid margin.

Figure 3. Chalazion on the superior lid

F. Differential Diagnosis

1. Preseptal cellulitis

In preseptal cellulitis there are complaints of warmth, edema and erythema

of the eyelids and periorbita.6,7

2. Sebaceous gland carcinoma

Suspect this in an elderly patient with recurrent chalazion, eyelid

thickening or chronic unilateral blepharitis.6,7

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 3. Pyogenic granuloma

Pedunculated, red, benign lesion often associated with chalazion,

hordeolum or eyelid surgery. Pyogenic granulomas can be excised or

treated with a combination of topical steroid antibiotics.6,7

G. Management

Although spontaneous resolution may occur in some patients with

chalazion, the standard treatment for chalazion is incision and curettage.

Minor surgical procedures can be stressful and uncomfortable for patients as

they require the use of dressings and bandages after surgery. The most

common management of chalazion is a conservative method using warm

compresses and antibiotic eye ointments.12

Conservative management is the initial strategy for chalazions. Warm

compresses should be applied to the affected eyelids for 15 minutes 2 to 4

times per day. Massage of the eyelids and possibly using baby shampoo on the

eyelids can also be effective. Most chalazions heal within a month with these

conservative measures. Antibiotics are not routinely needed as this is an

inflammatory condition. Antibiotics may be given if there is an associated

infection. If there is no evidence of infection, intralesional steroids can be

used. Injection of 0.2 to 2 mL of 40 mg/mL triamcinolone solution is the usual

choice. Larger lesions may require repeat injection in 2 to 7 days. Persistent

lesions require surgical intervention. Smaller lesions can be treated with

surgical curettage and dissection. Larger lesions require more extensive

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excision. Recurrent chalazion should be biopsied to rule out sebaceous cell

carcinoma.7

Generally, acute internal hordeolum lasts one to two weeks, beginning

with the appearance of the abscess and ending with drainage of the abscess.

Initial treatment for hordeolum is aimed at draining the pus from the abscess

and relieving meibomian gland obstruction. Warm or hot compresses can

facilitate drainage by removing the granuloma. Hot compresses are usually

used for five to 10 minutes, several times a day, until the hordeolum resolves.

Scrub the eyelids with a mild shampoo or saline solution, and gently massage

the affected area. Use of an eyelid scrub for cleanliness and drainage of the

eyelid margins.2,13

Antibiotics can be given locally, at the site of infection, or can be given

systemically. Topical application of antibiotics can reduce healing time by

fighting infection-causing bacteria and reducing inflammation. Systemic

antibiotics are sometimes used when local antibiotics are ineffective, or when

the infection is not localized.2,13

When medical management has failed, injectable steroids have been

shown to be effective in reducing the size of the lesion by at least 80%.

Steroids can be applied as ointments or eye drops.

Intralesional steroid injection may be a good option when the chalazion is

located near the canaliculus. Incision and curettage is considered the more

definitive treatment, although recurrence is known to occur afterward.2,13

Indications for chalazion excision:3

1. Chalazion unresponsive to medical management

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 2. Large size (big enough to feel)

3. cosmetic deformity

4. Vision problems (eg, astigmatism or blurred vision due to pressure in

the eye)

5. Patient requests

Contraindications for excision of chalazion:3

1. Chalazion recently dried (relative contraindication)

2. Crusty or inflamed skin

3. Anticoagulant patients (relative contraindications).

4. Chalazion near the lacrimal punctum. If the chalazion is close enough

to the punctum that it could be damaged, the patient should be referred

to an ophthalmologist for excision.

Indications for incision and drainage of hordeolum:

1. Hordeolum failed medical management

2. Hordeolum causes significant pain

3. Hordeolum with significant local accumulation of pus

4. Previous or current eyelid cellulitis associated with hordeolum

Contraindicated for incision and drainage of hordeolum. If the hordeolum

is located near the lacrimal punctum, refer the patient to an ophthalmologist

because of the risk of damage to the lacrimal drainage system.3

H. Complications

Some complications that can occur in hordeolum and chalazion:8

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 1. Slow increase in size is often seen and may eventually become very large.

On the external hordeolum can form chalazion.

2. Fungal massof granulation tissue sometimes forms when the lesion

ruptures on the conjunctival side.

3. Secondary infection can cause the formation of an internal hordeolum in

chalazion

4. Calcifications can occur, although they are very rare.

5. Malignant changes such as meibomian gland adenocarcinoma (sebaceous

cell carcinoma) may be seen occasionally in the elderly.

I. Prognosis

Most hordeolum and chalazion do not affect vision unless they are very

large. In general, the lesions will heal on their own or after medical or surgical

treatment.9

If the hordeolum causes any of the following problems, the patient should

see an eye doctor:9

- Disturbing vision.

- Often occurs with successive infections.

- Does not disappear by itself.

- Does not respond to self-care.

- There is redness and swelling that extends beyond the lids to the face or

cheeks.

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