REVIEW ARTICLE

Eyelid Inflammation: Approach to Hordeolum,

chalazion, and Pyogenic Granuloma
Leonid Skorin Jr, Do, On, MS, and Laura Goemann, BA

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.

KEYWORDS: Hordeolum, chalazion, pyogenic granuloma, eyelids

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.

282 CONSULTANT - May 2017 - www.consultant360.com

 Eyelid Inflammation: Approach to Hordeolum, Chalazion, and Pyogenic Granuloma
bump on the eyelid as the infected meibomian gland becomes
painful, erythematous, and swollen.‘ The acute infection is
most commonly caused by Stapbylococcu: aureus and may coin-
cide with blepharitis.‘ Internal hordeolum may also be associat-
ed with rosacea, trichiasis (inward-turned eyelashes), or ectropi-
on.5 The meibomian glands are closer to the palpebral conjunc-
tiva; 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).
An internal hordeolum may spontaneously resolve, although
certain treatments can promote more rapid drainage. Conserva-
tive treatments include using warm compresses applied for 5 to
10 minutes 2 to 4 times a day.“ 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 tempera-
ture of approximately 405°C, requiring frequent reheating.7
An alternative treatment is using commercially produced, mi-
crowave-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.‘ 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.‘ Penicillinase-resistant penicillins such as di-
cloxacillin, 125 to 250 mg every 6 hours, or amoxicillin clavu-
lanate, 250 mg every 8 hours, usually are eflective at resolving
the internal hordeolum.” Alternative antibiotics in patients with
penicillin allergy are oral levofloxacin, 500 mg once a day;
trimethoprim-sulfamethoxazole, 200 mg once a day; or cepha-
lexin, 250 to 500 mg every 6 hours for 1 to 2 weeks.7"° If the
infection remains unresolved, surgical incision and drainage
may be necessary? This allows the purulent material from the
infection to drain. Topically applied ophthalmic antibiotic oint-
ment after drainage serves to prevent secondary infection.°
EXTERNAL HURUEULUM
When the glands of Moll or Zeis are infected, it is referred to
as an external hordeolum. The infection occurs within the lu-
men of either gland, causing tender, erythematous swelling near
the lid margin.“ These glands are anterior to the tarsal plate and
Chalazion on the lower eyelid.
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 forma-
tion of the point.° 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."
An external hordeolum will usually resolve spontaneously
and is generally shorter-lasting and less painful than an internal
hordeolum} Conservative treatment is applied first, reserving
surgical options for the persistent, nonresolving external
hordeolum. Similar to internal hordeolum therapy, warm com-
_ presses are the first-line treatment for hastening the pointing
and drainage of the external hordeolum. However, topical oph-
thalmic antibiotics are effective in hastening the resolution of
an external hordeolum, unlike with an internal hordeolum.
Topical antibiotics, such as bacitracin or erythromycin ophthal-
mic ointment applied 4 times a day during the acute phase and
continually twice daily for 1 week, prevent infection in adjacent
lash follicles.” 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.°'”
CHALAZIUN
Chalazia occur when there is obstruction and subsequent in-
flammation of the sebaceous glands of the eyelid. Either the
meibomian glands or glands of Zeis may be affected. When a
www.consultant360.com 0 May 2017 0 CONSULTANT 283
Eyelid Inflammation: Approach to Hordeolum, chalazion, and Pyogenic Granuloma
Pyogenic granuloma seen at the upper eyelid margin.
chalazion develops in a gland of Zeis, it is known as a marginal
chalazion and presents at the lid margin.” Chalazia are not in-
fectious but rather are chronic, sterile lipogranulomatous in-
flammation occurring within the glands (Figure 3).° Unlike a
hordeolum, chalazia are hard, immobile, and painless. Chalazia
are more commonly found on the upper lid and vary in size.”
Chalazia may evolve from an unresolved hordeolum and are
often associated with seborrheic blepharitis and rosacea.”
Conservative treatment of a chalazion includes warm com-
presses 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.“ Topical
and oral antibiotics are not effective, since chalaziaare not in-
fectious. 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 dox-
ycycline, 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. In-
jection of corticosteroids into the mass or surgical removal are
interventions considered for these nonresolving lesions.
Corticosteroids can be injected either intralesionally or sub-
cutaneously to help improve resolution of the chalazion. Corti-
costeroids target the inflammatory components of the chalazi-
on and inhibit additional histiocyte, multinucleated giant cells,
lymphocytes, plasma cells, polymorphonuclear leukocytes, and
eosinophils from further accumulation.” This treatment increas-
es the successful resolution in 50% to 95% of cases.” A higher
concentration of corticosteroid should be used, since the chala-
284 CONSULTANT - May 2017 0 www.consultant360.com
Pyogenic granuloma is more easily visualized with eversion of
the upper eyelid.
zion is encapsulated by connective tissue, allowing limited vol-
ume to be injected into the lesion." Triamcinolone acetonide,
40 mg/mL concentration, is a suitable corticosteroid due to its
high concentration and small dosage of O. 10 to 0.20 mL.‘5 Res-
olution of the chalazion usually occurs 1 or 2 weeks following
a single injection.° However, for a larger chalazion, a second
injection may be necessary for full resolution.”
Corticosteroid injection should not be used in dark-skinned
patients, since depigmentation may occur.” \X/hen depigmen-
tation occurs, it is usually reversible.” Other less serious compli-
cations include pain at the injection site, temporary skin atro-
phy, 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.“ 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.”
A chalazion may be surgically removed if unresolved follow-
ing corticosteroid injection, or if injection is not indicated. Sur-
gical 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 conjuncti-
va and affected meibomian gland. The everted eyelid is stabi-
lized using a chalazion clamp during the procedure, and the
clamp also helps maintain hemostasis. An incision is made us-
ing 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 us-
ing 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.
 Eyelid Inflammation: Approach to Hordeolum, chalazion, and Pyogenic Granuloma
Following hemostasis, ophthalmic antibiotic ointment is ap-
plied to the wound. No sutures are required, and healing occurs
through secondary intention. (View a 2-minute video ofa sur-
gical removal of a chalazion by the authors at www.consul-
tant360.com/ChalazionRemoval.)
Ifa chalazion recurs in the same location, suspicion of seba-
ceous gland carcinoma should be raised. Sebaceous gland carci-
noma is an adnexal epithelial tumor that has a predilection for
the eyelid.” The incidence of sebaceous gland carcinoma is low,
but the risk of mortality is high, and a correct diagnosis is im-
portant. Sebaceous gland carcinomas often are initially misdi-
agnosed 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.
PYUGENIC GRANULUMA
Pyogenic granulomas are vascular lesions commonly occur-
ring on skin and mucosa, including the palpebral conjunctiva.
The name itself is a misnomer, since these lesions are neither
infectious (pyogenic) not inflammatory (granulomatous). The
exact etiology is unknown, but the granuloma is often associat-
ed with a chalazion, a hordeolum, or a history of trauma or
surgery.” These nodules also occur rarely in the anophthalmic
socket following enucleation and at the margin of corneal
transplants. ' "
Pyogenic granuloma presents as a nontender, fleshy, red, vas-
cular lesion.” The lesions are typically sessile or pedunculated,
are dome—shaped, and vary from 1 to 10 mm in diameter.” The
mass is a collection of granulation tissue such as chronic in-
flammatory cells, fibroblasts, and endothelial cells of budding
capillaries (Figures 4 and 5).: Most pyogenic granulomas are
asymptomatic but may bleed easily or cause mild discomfort.“
Differentiating pyogenic granulomas from malignant lesions
avoids unnecessary treatment, since pyogenic granulomas are
always benign. A major distinguishing factor is the rate ofle—
sion formation. The pyogenic granuloma will form rapidly,
whereas malignancies such as squamous cell carcinoma develop
slowly.” 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 topi-
cal therapies varies among patients from a decrease in size to
full resolution or no effect at all. Topical corticosteroids pre-
scribed 4 times a day for 1 to 2 weeks may reduce the lesions.“
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."‘33 If the lesion is sessile, sur-
gical excision with a deep, narrow ellipse will provide the small-
est risk of recurrence.“ Recurrence is uncommon with surgical
excision, but the risk rises when granulation tissue remains.“
Care is taken when the eyelid margin is involved to avoid com-
promising the integrity of this structure. I
Leonid Skorin Jr, DO, OD, MS, is an ophthalmologist at the
Mayo Clinic Health System in Albert Lea, Minnesota.
Laura Goemann, BA, is it fourth-year optometry student at
Pacific University! College of Optometry in Forest Grove, Oregon.
REFERENCES:
1. Remington LA. Ocular adnexa and lacrimal system. In: Remington LA. Clini-
cal Anatomy and Physiology of the Visual System. 3rd ed. St Louis, MO:
Butterworth Heinemann Elsevier; 2012:159-181.
2. Bron AJ. Tnpathi RC, Tripathi BJ. The ocular appendages: eyelids. conjunc-
tiva and lacrimal apparatus. in: Bron AJ. Tripathi RC, Tripathi BJ. Wolff's
Anatomy of the Eye and Orbit. 8th ed. London, England: Chapman & Hall
Medical; 1997230-84.
3. Hirunwiwatkul P, Wachirasereechai K. Effectiveness of combined antibiotic
ophthalmic solution in the treatment of hordeolum after incision and curet-
tage: a randomized, placebo-controlled trial: a pilot study. J Med Assoc Thai.
2005:88(5):647-650.
4. Dutton JJ. Clinical anatomy of the eyelids. in: Yanoff M, Duker JS, eds. Oph-
thalmology. 3rd ed. Philadelphia, PA: Mosby Elsevier; 2009:1379—1433.
5. Lindsley K, Nichols JJ, Dickersin K. Interventions for acute internal hordeo-
lum. Cochrane Database Syst Rev. 2013;(4):CDOO7742. doi:10.1002/
14651858.CDOO7742.pub3
6. Kaufman HE, Barron BA, McDonald MB, Kaufman SC, eds. Companion
Handbook to the Cornea. 2nd ed. Boston, MA: Butterworth Heinemann;
2000:29-33.
7. Piccolo MG, Malinovsky V. Hordeolalchalazia/meibomitis (meibomianitis). ln:
Onolrey BE, Skorin L Jr, Holdeman NR, eds. Ocular Therapeutics Hand-
book: A Clinical Manual. 3rd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2011:186—191.
8. Bertucci GM. Periocular skin lesions and common eyelid tumors. in: Chen
WP, ed. Oculoplastic Surgery: The Essentials. New York, NY: Thieme; 2001:
225-241.
9. Lambreghts KA, Melore GG. Disease of the eyelids. In: Bartlett JD, Jaanus
SD, eds. Clinical Ocular Pharmacology. 5th ed. St Louis. MO: Butterworth
Heinemann Elsevier; 2008:381—413.
10. Melton R, Thomas R. Clinical guide to ophthalmic drugs. Rev Optom.
2016;(Suppl):6-12.
11. Alexander KL. Some inflammations of the external eye and adnexa. J Am
Optom Assoc. l980;51(2):142-147.
12. Ostler HB, Maibach Hl. Hoke AW, Schwab IR. Epidermal skin tumors. in:
Ostler HB, Maibach Hl. Hoke AW, Schwab IR. Diseases of the Eye & Skin: A
Color Atlas. Philadelphia. PA: Lippincott Williams & Wilkins; 2004:179-203.
13. Ben Simon GJ, Rosen N, Rosner M, Spierer A. intralesional triamcinolone
acetonide injection versus incision and curettage for primary chalazia: a pro-
spective. randomized study. Am J Ophthalmol. 2011;15l(4):714-718.e1.
14. Black RL. Terry JE. Treatment of chalazia with intralesional triamcinolone in-
jection. J Am Optom Assoc. 1990:61(12):904-906.
15. Pavan-Langston D, Colby K. Cornea and external disease. in: Pavan-
Langston D, ed. Manual of Ocular Diagnosis and Therapy 6th ed. Philadel-
phia. PA: Wolters Kluwer Lippincott Williams & Wilkins; 2008:73—138.
16. Thomas EL, Laborde RP. Retinal and choroidal vascular occlusion following
intralesional corticosteroid injection of a chalazion. Ophthalmology. 1986:
93(3):405-407.
17. Francis BA, Chang EL, Haik BG. Particle size and drug interactions of inject-
able corticosteroids used in ophthalmic practice. Ophthalmology. 1996:
103(11):1884-1888.
18. Pierson JC. Dermatologic manilestations of pyogenic granuloma (lobular
capillary hemangioma). Medscape. http:l/emedicine.medscape.comlarticiel
1084701—overview. Updated February 19, 2016. Accessed April 25, 2017.
19. Skorin L Jr, Corneal and eyelid anomalies. Consultant. 2000;40(2):265-272.
20. Papadopoulos M. Snibson GR, McKeivie PA. Pyogenic granuloma of the cor-
nea. Aust N ZJ Ophthalmol. 1998:26(2):185-188.
21. Pyogenic granuloma. ln: Gerstenblith AT. Rabinowitz MP, eds. The Wills Eye
Manual: Office and Emergency Room Diagnosis and Treatment of Eye Dis-
ease. 6th ed. Philadelphia, PA: Wolters Kluwer Lippincott Williams & Wilkins;
2012130.
22. Lawley LP. Pyogenic granuloma (lobular capillary hemangioma). UpToDale.
http:llwww.uptodate.comlcontents/pyogenic—granuloma-lobu|ar—capil|ary—
hemangioma. Updated April 25, 2016. Accessed April 25, 2017.
www.consu|tant360.com - May 2017 0 CONSULTANT 285