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ABSTRACT:Internal and external hordeolum, chalazion, and pyogenic granuloma are common lesions that present
on the eyelid. Proper diagnosis and management can result in a reduction of a patient’s symptoms and an in-
creased rate of resolution. This article reviews the involved anatomy, frequent clinical findings, and treatment
recommendations about these common lesions for the primary care provider.
hen infections and inflammation occur on the eyelids, The tarsal plate surrounds and protects modified sebaceous
wthey have very specific etiologies. The infectious and glands called meibomian glands. These glands secrete lipid
inflammatory responses that result are differentiated through openings along the eyelid margin that contributes to
based on the anatomic structures involved. Accurate evaluation the tear film stability. There are approximately 30 to 40 meibo-
of these lesions is central to effective management, because mian glands along the upper lid and 20 to 30 on the lower lid.‘
treatments are specific to eachunderlying etiology. In order to The eyelashes on the eyelid margin are anterior to the mei-
accurately diagnose and manage eyelid lesions, it is crucial to bomian glands. The eyelashes are surrounded by the ciliary
have an understanding of the anatomy involved. glands of Moll (apocrine) and the glands of Zeis (sebaceous).2
The glands of Zeis secrete sebum that coats the eyelashes, pro-
ANATOMY UF THE EYELIDS tecting them from becoming brittle.” The glands of Moll se-
The skin of the eyelid is the thinnest in the body and lacks crete into the hair follicle, into the glands of Zeis, or onto the
adipose tissue.‘ The innermost layer of tissue that lies adjacent lid margin.” The location of these glands is important in un-
to the globe is referred to as the palpebral conjunctiva. Anterior derstanding the conditions discussed below.
to the palpebral conjunctiva is the tarsal plate, a structure with-
in the eyelid that provides its rigidity and shape. Between the INTERNAL HURIJEULUM
tarsal plate and outermost layer of skin is muscle tissue com- An infection within the meibomian gland is referred to as an
posed of the orbicularis oculi and levator palpebrae superioris. internal hordeolum} The patient will present with a tender, red
Advanced internal hordeolum revealed with eversion of the External hordeolum on the upper eyelid with a pointed lesion at
lower eyelid. the eyelid margin.
chalazion develops in a gland of Zeis, it is known as a marginal zion is encapsulated by connective tissue, allowing limited vol-
chalazion and presents at the lid margin.” Chalazia are not in- ume to be injected into the lesion." Triamcinolone acetonide,
fectious but rather are chronic, sterile lipogranulomatous in- 40 mg/mL concentration, is a suitable corticosteroid due to its
flammation occurring within the glands (Figure 3).° Unlike a high concentration and small dosage of O. 10 to 0.20 mL.‘5 Res-
hordeolum, chalazia are hard, immobile, and painless. Chalazia olution of the chalazion usually occurs 1 or 2 weeks following
are more commonly found on the upper lid and vary in size.” a single injection.° However, for a larger chalazion, a second
Chalazia may evolve from an unresolved hordeolum and are injection may be necessary for full resolution.”
often associated with seborrheic blepharitis and rosacea.” Corticosteroid injection should not be used in dark-skinned
Conservative treatment of a chalazion includes warm com- patients, since depigmentation may occur.” \X/hen depigmen-
presses and lid massages to attempt to evacuate the inflamed tation occurs, it is usually reversible.” Other less serious compli-
gland. Lid massages are done following warm compresses, and cations include pain at the injection site, temporary skin atro-
patients are instructed to gently compress the lid with their phy, and subcutaneous white (corticosteroid) deposits.9 This
index finger and roll toward the lid margin. If the mass is small, technique is safe and effective. Very rarely, retinal and choroidal
compresses and massage are more likely to be effective.“ Topical vascular occlusions immediately after a corticosteroid injection
and oral antibiotics are not effective, since chalaziaare not in- from embolization have been reported.“ To minimize the
fectious. Oral tetracyclines may be used, but their efficacy is chances of this occurring, practitioners should aspirate for
not due to their antibiotic properties.7 Tetracyclines stabilize the blood before injecting, take care to inject slowly, and avoid
free fatty acids produced when meibomian lipids break down, heavy digital pressure during and after injection.”
thus reducing the stimuli for granuloma formation.7 Oral dox- A chalazion may be surgically removed if unresolved follow-
ycycline, 50 to 100 mg twice a day, or oral tetracycline, 250 mg ing corticosteroid injection, or if injection is not indicated. Sur-
4 times a day for 3 to 4 weeks, usually results in resolution.7 If gical removal is done under local anesthetic using lidocaine. A
the chalazion persists, more-invasive treatment is required. In- suture is placed through the eyelid near the margin and used as
jection of corticosteroids into the mass or surgical removal are a fulcrum to evert the eyelid, exposing the palpebral conjuncti-
interventions considered for these nonresolving lesions. va and affected meibomian gland. The everted eyelid is stabi-
Corticosteroids can be injected either intralesionally or sub- lized using a chalazion clamp during the procedure, and the
cutaneously to help improve resolution of the chalazion. Corti- clamp also helps maintain hemostasis. An incision is made us-
costeroids target the inflammatory components of the chalazi- ing a trephine blade to expose the lumen of the inflamed gland.
on and inhibit additional histiocyte, multinucleated giant cells, The granulomatous material can then be scraped out using a
lymphocytes, plasma cells, polymorphonuclear leukocytes, and curette. The encapsulating connective tissue is also excised us-
eosinophils from further accumulation.” This treatment increas- ing curved iris scissors to reduce the rate of recurrence. After
es the successful resolution in 50% to 95% of cases.” A higher complete removal of the inflammatory material, the chalazion
concentration of corticosteroid should be used, since the chala- clamp is removed, and pressure is applied to stop any bleeding.
Following hemostasis, ophthalmic antibiotic ointment is ap- Care is taken when the eyelid margin is involved to avoid com-
plied to the wound. No sutures are required, and healing occurs promising the integrity of this structure. I
through secondary intention. (View a 2-minute video ofa sur-
gical removal of a chalazion by the authors at www.consul- Leonid Skorin Jr, DO, OD, MS, is an ophthalmologist at the
tant360.com/ChalazionRemoval.) Mayo Clinic Health System in Albert Lea, Minnesota.
Ifa chalazion recurs in the same location, suspicion of seba-
ceous gland carcinoma should be raised. Sebaceous gland carci- Laura Goemann, BA, is it fourth-year optometry student at
noma is an adnexal epithelial tumor that has a predilection for Pacific University! College of Optometry in Forest Grove, Oregon.
the eyelid.” The incidence of sebaceous gland carcinoma is low,
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