Eyelid Inflammation: Approach to Hordeolum, Chalazion, and Pyogenic Granuloma

Authors:
Leonid Skorin Jr, DO, OD, MS, and Laura Goemann, BA

Citation:
Skorin L, Goemann L. Eyelid inflammation: approach to hordeolum, chalazion, and pyogenic granuloma. Consultant. 2017;57(5):282-285.

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 increased rate of resolution. This article reviews the involved anatomy, frequent clinical findings, and treatment recommendations about these common lesions for the primary care provider.

KEYWORDS: Hordeolum, chalazion, pyogenic granuloma, eyelids

When infections and inflammation occur on the eyelids, they have very specific etiologies. The infectious and inflammatory responses that result are differentiated based on the anatomic structures involved. Accurate evaluation of these lesions is central to effective management, because treatments are specific to each underlying etiology. In order to accurately diagnose and manage eyelid lesions, it is crucial to have an understanding of the anatomy involved.

Anatomy of the Eyelids

The skin of the eyelid is the thinnest in the body and lacks adipose tissue.¹ The innermost layer of tissue that lies adjacent to the globe is referred to as the palpebral conjunctiva. Anterior to the palpebral conjunctiva is the tarsal plate, a structure within the eyelid that provides its rigidity and shape. Between the tarsal plate and outermost layer of skin is muscle tissue composed of the orbicularis oculi and levator palpebrae superioris. The tarsal plate surrounds and protects modified sebaceous glands called meibomian glands. These glands secrete lipid through openings along the eyelid margin that contributes to the tear film stability. There are approximately 30 to 40 meibomian glands along the upper lid and 20 to 30 on the lower lid.¹

The eyelashes on the eyelid margin are anterior to the meibomian glands. The eyelashes are surrounded by the ciliary glands of Moll (apocrine) and the glands of Zeis (sebaceous).² The glands of Zeis secrete sebum that coats the eyelashes, protecting them from becoming brittle.^1,2 The glands of Moll secrete into the hair follicle, into the glands of Zeis, or onto the lid margin.^1,2 The location of these glands is important in understanding the conditions discussed below.

Internal Hordeolum

An infection within the meibomian gland is referred to as an internal hordeolum.³ The patient will present with a tender, red bump on the eyelid as the infected meibomian gland becomes painful, erythematous, and swollen.⁴ The acute infection is most commonly caused by Staphylococcus aureus and may coincide with blepharitis.⁴ Internal hordeolum may also be associated with rosacea, trichiasis (inward-turned eyelashes), or ectropion.⁵ The meibomian glands are closer to the palpebral conjunctiva; therefore, the abscess of the internal hordeolum will be visible only when the eyelid is everted. Without eversion, only generalized swelling will be apparent, since the muscle tissue anterior to the meibomian glands and the tarsal plate block visualization of the lesion. A yellow lesion will be seen on the palpebral conjunctiva in advanced cases (Figure 1).

Advanced internal hordeolum revealed with eversion of the lower eyelid.

An internal hordeolum may spontaneously resolve, although certain treatments can promote more rapid drainage. Conservative treatments include using warm compresses applied for 5 to 10 minutes 2 to 4 times a day.⁶ The heat softens the granuloma and lipids, allowing the material to drain more easily. Patients are instructed to use warm water and place a clean washcloth over their closed eyes. The disadvantage of this method is the length of time the washcloth remains at an effective temperature of approximately 40.5˚C, requiring frequent reheating.⁷ An alternative treatment is using commercially produced, microwave-heated eye compresses, which maintain optimal heat consistently that lasts longer without needing to be reheated. In addition, eyelid scrubs are beneficial to prepare the area for drainage. A diluted solution of baby shampoo and water is nonirritating to the eyes and can be used to clean the lids. Commercially prepared wipes with gentle shampoo are also available and effective to clear debris from the eyelid margin.

If the lesion has not resolved or appears to be spreading to adjacent glands after the use of warm compresses and lid wipes, an oral antibiotic should be prescribed.⁸ Topical antibiotics are not effective for treatment of an internal hordeolum, since the infection occurs deep within the tarsal plate. The antibiotic should be effective against S aureus, the species that is usually the primary cause.⁴ Penicillinase-resistant penicillins such as dicloxacillin, 125 to 250 mg every 6 hours, or amoxicillin clavulanate, 250 mg every 8 hours, usually are effective at resolving the internal hordeolum.⁹ Alternative antibiotics in patients with penicillin allergy are oral levofloxacin, 500 mg once a day; trimethoprim-sulfamethoxazole, 200 mg once a day; or cephalexin, 250 to 500 mg every 6 hours for 1 to 2 weeks.^7,10 If the infection remains unresolved, surgical incision and drainage may be necessary.⁹ This allows the purulent material from the infection to drain. Topically applied ophthalmic antibiotic ointment after drainage serves to prevent secondary infection.⁹

External Hordeolum

When the glands of Moll or Zeis are infected, it is referred to as an external hordeolum. The infection occurs within the lumen of either gland, causing tender, erythematous swelling near the lid margin.⁸ These glands are anterior to the tarsal plate and muscle tissue, allowing the abscess to be seen without eyelid eversion. At the lid margin, a pointed lesion develops within a few days after the initial swelling (Figure 2). Spontaneous draining of the abscess occurs 3 to 4 days following the formation of the point.⁹ The external hordeolum is commonly caused by an acute S aureus infection and, in advanced cases, can spread, leading to preseptal cellulitis. The external hordeolum is commonly associated with blepharitis, fatigue, poor diet, and stress and can be recurrent.¹¹

External hordeolum on the upper eyelid with a pointed lesion at the eyelid margin.

An external hordeolum will usually resolve spontaneously and is generally shorter-lasting and less painful than an internal hordeolum.⁵ Conservative treatment is applied first, reserving surgical options for the persistent, nonresolving external hordeolum. Similar to internal hordeolum therapy, warm compresses are the first-line treatment for hastening the pointing and drainage of the external hordeolum. However, topical ophthalmic antibiotics are effective in hastening the resolution of an external hordeolum, unlike with an internal hordeolum. Topical antibiotics, such as bacitracin or erythromycin ophthalmic ointment applied 4 times a day during the acute phase and continually twice daily for 1 week, prevent infection in adjacent lash follicles.^3,9 Epilation of the involved eyelash can also be used to hasten resolution of the external hordeolum by creating a drainage channel for the infected material.

If conservative treatment is ineffective, oral antibiotics should be prescribed. Cephalexin or dicloxacillin dosed as above may help resolve the infection and may be necessary in cases that have evolved into preseptal cellulitis. If the infection remains unresolved, surgical incision and drainage may be necessary.^9,11

Chalazion

Chalazia occur when there is obstruction and subsequent inflammation of the sebaceous glands of the eyelid. Either the meibomian glands or glands of Zeis may be affected. When a chalazion develops in a gland of Zeis, it is known as a marginal chalazion and presents at the lid margin.¹² Chalazia are not infectious but rather are chronic, sterile lipogranulomatous inflammation occurring within the glands (Figure 3).⁹ Unlike a hordeolum, chalazia are hard, immobile, and painless. Chalazia are more commonly found on the upper lid and vary in size.¹² Chalazia may evolve from an unresolved hordeolum and are often associated with seborrheic blepharitis and rosacea.^4,9

Chalazion on the lower eyelid.

Conservative treatment of a chalazion includes warm compresses and lid massages to attempt to evacuate the inflamed gland. Lid massages are done following warm compresses, and patients are instructed to gently compress the lid with their index finger and roll toward the lid margin. If the mass is small, compresses and massage are more likely to be effective.⁶ Topical and oral antibiotics are not effective, since chalazia are not infectious. Oral tetracyclines may be used, but their efficacy is not due to their antibiotic properties.⁷ Tetracyclines stabilize the free fatty acids produced when meibomian lipids break down, thus reducing the stimuli for granuloma formation.⁷ Oral doxycycline, 50 to 100 mg twice a day, or oral tetracycline, 250 mg 4 times a day for 3 to 4 weeks, usually results in resolution.⁷ If the chalazion persists, more-invasive treatment is required. Injection of corticosteroids into the mass or surgical removal are interventions considered for these nonresolving lesions.

Corticosteroids can be injected either intralesionally or subcutaneously to help improve resolution of the chalazion. Corticosteroids target the inflammatory components of the chalazion and inhibit additional histiocyte, multinucleated giant cells, lymphocytes, plasma cells, polymorphonuclear leukocytes, and eosinophils from further accumulation.⁸ This treatment increases the successful resolution in 50% to 95% of cases.¹³ A higher concentration of corticosteroid should be used, since the chalazion is encapsulated by connective tissue, allowing limited volume to be injected into the lesion.¹⁴ Triamcinolone acetonide, 40 mg/mL concentration, is a suitable corticosteroid due to its high concentration and small dosage of 0.10 to 0.20 mL.¹⁵ Resolution of the chalazion usually occurs 1 or 2 weeks following a single injection.⁹ However, for a larger chalazion, a second injection may be necessary for full resolution.⁹

Corticosteroid injection should not be used in dark-skinned patients, since depigmentation may occur.¹⁵ When depigmentation occurs, it is usually reversible.⁹ Other less serious complications include pain at the injection site, temporary skin atrophy, and subcutaneous white (corticosteroid) deposits.⁹ This technique is safe and effective. Very rarely, retinal and choroidal vascular occlusions immediately after a corticosteroid injection from embolization have been reported.¹⁶ To minimize the chances of this occurring, practitioners should aspirate for blood before injecting, take care to inject slowly, and avoid heavy digital pressure during and after injection.¹⁷

A chalazion may be surgically removed if unresolved following corticosteroid injection, or if injection is not indicated. Surgical removal is done under local anesthetic using lidocaine. A suture is placed through the eyelid near the margin and used as a fulcrum to evert the eyelid, exposing the palpebral conjunctiva and affected meibomian gland. The everted eyelid is stabilized using a chalazion clamp during the procedure, and the clamp also helps maintain hemostasis. An incision is made using a trephine blade to expose the lumen of the inflamed gland. The granulomatous material can then be scraped out using a curette. The encapsulating connective tissue is also excised using curved iris scissors to reduce the rate of recurrence. After complete removal of the inflammatory material, the chalazion clamp is removed, and pressure is applied to stop any bleeding. Following hemostasis, ophthalmic antibiotic ointment is applied to the wound. No sutures are required, and healing occurs through secondary intention. (View a 2-minute video of a surgical removal of a chalazion by the authors at www.consultant360.com/ChalazionRemoval.)

If a chalazion recurs in the same location, suspicion of sebaceous gland carcinoma should be raised. Sebaceous gland carcinoma is an adnexal epithelial tumor that has a predilection for the eyelid.¹² The incidence of sebaceous gland carcinoma is low, but the risk of mortality is high, and a correct diagnosis is important. Sebaceous gland carcinomas often are initially misdiagnosed as a chalazion, and all suspicious chalazia should be sent for histopathologic analysis. A recurrent hordeolum raises no such concern, since recurrences typically result from failure to completely eliminate the initial bacteria.

Pyogenic Granuloma

Pyogenic granulomas are vascular lesions commonly occurring on skin and mucosa, including the palpebral conjunctiva. The name itself is a misnomer, since these lesions are neither infectious (pyogenic) nor inflammatory (granulomatous). The exact etiology is unknown, but the granuloma is often associated with a chalazion, a hordeolum, or a history of trauma or surgery.¹⁸ These nodules also occur rarely in the anophthalmic socket following enucleation and at the margin of corneal transplants.¹⁹

Pyogenic granuloma presents as a nontender, fleshy, red, vascular lesion.¹² The lesions are typically sessile or pedunculated, are dome-shaped, and vary from 1 to 10 mm in diameter.¹⁸ The mass is a collection of granulation tissue such as chronic inflammatory cells, fibroblasts, and endothelial cells of budding capillaries (Figures 4 and 5).² Most pyogenic granulomas are asymptomatic but may bleed easily or cause mild discomfort.⁸

Pyogenic granuloma seen at the upper eyelid margin.

Pyogenic granuloma is more easily visualized with eversion of the upper eyelid.

Differentiating pyogenic granulomas from malignant lesions avoids unnecessary treatment, since pyogenic granulomas are always benign. A major distinguishing factor is the rate of lesion formation. The pyogenic granuloma will form rapidly, whereas malignancies such as squamous cell carcinoma develop slowly.²⁰ Suspicious lesions should be surgically removed and sent for histopathologic testing to confirm the diagnosis.

Pyogenic granulomas rarely resolve spontaneously. If they are asymptomatic, no treatment is necessary. The response to topical therapies varies among patients from a decrease in size to full resolution or no effect at all. Topical corticosteroids prescribed 4 times a day for 1 to 2 weeks may reduce the lesions.²¹ However, there may be no response at all. If the lesion persists, surgical excision is required.

Removal of a single pedunculated lesion is done using a shave excision and electrocautery.^8,22 If the lesion is sessile, surgical excision with a deep, narrow ellipse will provide the smallest risk of recurrence.²² Recurrence is uncommon with surgical excision, but the risk rises when granulation tissue remains.⁸ Care is taken when the eyelid margin is involved to avoid compromising the integrity of this structure.

Leonid Skorin Jr, DO, OD, MS, is an ophthalmologist at the Mayo Clinic Health System in Albert Lea, Minnesota.

Laura Goemann, BA, is a fourth-year optometry student at Pacific University College of Optometry in Forest Grove, Oregon.

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