CHAPTER 65

CHALAZION AND HORDEOLUM

James L. Jackson

Patients with a chalazion or hordeolum, focal inflammatory condi-
tions of the eyelids, are frequently encountered in primary care.
Invariably they complain of a “stye.” Both conditions may be treated
by the prudent nonophthalmologist using a minor surgical procedure
in the office setting. However, care must be taken not to injure the
eye, the eyelid, or sensitive components, particularly the lacrimal
drainage system (“tear ducts”) or the eyelid margin.
A chalazion (Fig. 65-1) is an acute or chronic granulomatous
inflammation of a meibomian gland in the eyelid. A hordeolum is an
acute abscess of a meibomian, Zeis’, or Moll’s gland (see Fig. 65-10).
An internal hordeolum points onto the conjunctival surface of the
lid, whereas an external hordeolum points onto the external surface
of the skin or the margin of the lid.
The meibomian glands are basically sebaceous glands located
deep within both eyelids (Fig. 65-2). They constantly produce a lipid
material that drains through long ducts and emerges from orifices at
the eyelid margin. This lipid material then enters the tear film to
help keep the surface of the eye lubricated while also slowing evap-
oration of the tears.
Meibomian secretions are naturally viscous, but under certain
conditions they become thick enough to plug the duct of the gland.
Because the gland continues to produce secretions, they must go
somewhere (similar to a sebaceous cyst); consequently, the secre-
tions eventually leak between the cells of the gland into the sur-
rounding tissue of the eyelid. Here, the secretions incite a chronic
granulomatous inflammatory reaction (chalazion). As more secre-
tions are produced, the inflammation worsens and it may smolder
chronically, sometimes for a year or longer.
Clinically, the inflammation causes localized swelling, edema, or
a nodule within the lid, sometimes associated with erythema and
mild tenderness. A chalazion may be located at the lid margin or up
to a few millimeters away. At times it may be prominent externally,
but more commonly a chalazion will be found on the inner (palpe-
bral conjunctiva) surface of the lid. Associated inflammation may
cause a soft or even liquid center, and patients may report spontane-
ous drainage internally, externally, or through the lid margin, which
may lead to clinical improvement or resolution. A chalazion may
also wax and wane.
Some people experience multiple chalazia over time or even
concurrently. Multiple chalazia are more commonly seen in people
with acne rosacea or chronic blepharitis. Chronic blepharitis is
characterized by eyelid margin inflammation, thickening, and ery-
thema associated with bacterial colonization and crusting at the base
of the eyelashes. Chronic blepharitis usually requires a slit-lamp
examination to make the diagnosis (see Chapter 67, Slit-Lamp
Examination); even with a slit lamp, the findings are often subtle
and not easily detected by the nonophthalmologist.
In contrast to a chalazion, a hordeolum is an acute bacterial
abscess of a meibomian, Zeis’, or Moll’s gland (see Fig. 65-2). Hor-
deola are classified as internal or external based on the primary
anatomic focus of the inflammation (which is usually obvious).
Typically characterized by an acute tender mass within the eyelid,
associated with erythema and a collection of pus, hordeola are often
accompanied by acute cellulitis of the eyelid. Such cellulitis, in turn,
is characterized by erythema, edema, and tenderness of the sur-
rounding skin. (“Eyelid cellulitis” is a different, much more localized
entity than the less common “orbital cellulitis,” a systemic, vision-
and life-threatening condition with which the patient is toxic with
a high fever.) A hordeolum usually drains spontaneously at 5 to 7
days, often relieving the symptoms. Hordeola are frequently associ-
ated with Staphylococcus infections and acute blepharitis, and these
both usually respond to antibiotics.
To differentiate a chalazion from a hordeolum can be a clinical
challenge. Although a hordeolum is usually more tender and tense
with obvious fluctuance, a chalazion may have a liquefied center;
however, it is usually not a collection of pus. The presence of sig-
nificant eyelid cellulitis also usually suggests a hordeolum, but a
chalazion may be associated with a degree of surrounding erythema
and edema (although it is usually to a lesser degree). The natural
history of a hordeolum is usually more acute; yet, a chalazion can
present acutely. It may also be important to differentiate a chalazion
or hordeolum from other eyelid disorders. If the swelling is located
nasal to the medial canthus (the corner where the upper and lower
eyelids meet), the patient likely has dacryocystitis rather than a
chalazion or hordeolum. In this situation, strongly consider prompt
referral to an ophthalmologist because dacryocystitis can lead to
serious sequelae. Because of the facial anatomy, bacterial dacryocys-
titis can dissect posteriorly to the cavernous sinus and beyond, with
grave consequences.
CHALAZION
Medical Management
A chalazion may respond to one or more of the following medical
treatments:
• Warm compresses to the eyelid (four times a day if possible).
• Eyelid scrubs of the lid margins at bedtime each night (at base of
eyelashes) with commercially available ocular cleansing pads or
diluted baby shampoo (diluted to half strength with water,
applied with a cotton swab or washcloth).
Figure 65-1  Chalazion, lower lid.

427

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428 EYES, EARS, NOSE, AND THROAT

Levator palpebrae Orbital septum

superioris muscle

Superior tarsal
muscle (of Müller)

Superior cul-de-sac

Eyebrow hair
Bulbar conjunctiva

Palpebral conjunctiva Tarsal plate

maintains
the support
Cornea of the lid
Embedded in the tarsal plate and the
subcutaneous tissue are several types Overlying
of secretory glands: orbicularis
oculi muscle Figure 65-2  Anatomy of the eyelid.
• Tarsal (meibomian) glands closes
in the tarsal plate secrete the eye
sebaceous material

• Zeis’ glands (rudimentary sweat

glands) attach to the lash follicles Skin

• Ciliary (Moll’s) glands (modified The innermost layer,

sweat glands) drain to the skin or closely adherent to
Zeis’ gland ducts the tarsal plate,
is the palpebral
conjunctiva

Meibomian
orifice

Eyelashes (cilia)

• Application of antibiotic ointment (usually erythromycin) to • Chalazion near the lacrimal punctum. The lacrimal punctum is
eyelid margin after washing. a tiny opening in the nasal aspect of each eyelid margin. Tears
• Oral doxycycline. drain through the punctum into the canaliculus, which runs just
• Intralesional steroid injection (e.g., triamcinolone acetonide) beneath the skin toward the nose. Damage to the punctum or
40 mg/mL, 0.2 to 0.4 mL, 30-gauge needle through the conjunc- canaliculus may lead to chronic tearing and the need for a com-
tival (inner) surface of the eyelid, after the use of topical anes- plicated surgical repair. If the chalazion is close enough to the
thesia (e.g., tetracaine drops). However, steroid injection carries punctum that there is a chance it has been damaged, the patient
the risk of skin hypopigmentation, especially in dark-skinned should be referred to an ophthalmologist for excision.
individuals.
Equipment
Indications for Excision See Figure 65-3.
• Chalazion unresponsive to medical management
• Substantial size (large enough to palpate) • Mask and goggles to follow universal blood and body fluid
• Cosmetic deformity precautions
• Visual problems (e.g., astigmatism, blurry vision) • Sterile tray
• Patient desires removal • Skin marking pen
• Topical ophthalmic anesthetic drops (e.g., tetracaine)
• Alcohol pads
Contraindications to Excision • Local anesthetic for injection (2% lidocaine with epinephrine),
• Chalazion that has recently drained through the skin or with very 3-mL syringe, 30-gauge needle
thin overlying skin (relative contraindication, increases risk of a • Povidone–iodine (Betadine) swabs
full-thickness “buttonhole” defect of the eyelid, leading to a • Sterile gloves
visible scar and prolonged healing time). • Sterile drape, fenestrated
• Skin crusted or markedly inflamed (excision is usually performed • Chalazion clamps (two or three sizes)
from the inner surface of the eyelid and, again, a “buttonhole” • Scalpel (no. 15 blade)
defect may result). • Chalazion curettes (two sizes)
• Anticoagulated patient (relative contraindication). • Cotton swabs

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 65  ——  CHALAZION AND HORDEOLUM 429

A
D

Figure 65-3  Instruments for chalazion excision. Top row, from left to
right: scalpel (no. 15 or no. 11 blade); chalazion clamps; chalazion curettes.
Bottom row, from left to right: ocular tissue forceps; needle holder; suturing E
forceps; Westcott conjunctival scissors.
Figure 65-4  Chalazion excision. A, Inject anesthetic. B, Place chalazion
clamp. C, Incise with scalpel, making an “X” over the lesion. D, Curette inte-
• Ocular tissue forceps, 0.2 tips rior of chalazion to remove soft, inflamed material. E, Remove small amount
of inflamed tarsus with Westcott conjunctival scissors and tissue forceps.
• Westcott conjunctival scissors
• 4 × 4 gauze pads
• Antibiotic–steroid combination ophthalmic ointment (e.g.,
Maxitrol or TobraDex)
will maintain hemostasis during the procedure. Do not over-
• Eyepatches (two or three) and medical tape
tighten. Evert the eyelid using the clamp as a lever (Fig. 65-5).
• Suture (6-0 nylon), needle holder, and suture scissors (only in
The chalazion should now be evident and bulging through the
event of full-thickness eyelid defect occurring as a complication)
opening of the clamp.
3. With a no. 15 blade, make two incisions in the form of a cross,
Preprocedure Patient Preparation taking care not to go through the eyelid skin but only into the
substance of the chalazion (Fig. 65-6; Fig. 65-4C). Some soft
Unless the patient is at high risk of cardiovascular events, he or she
material may be released, confirming that the incision is in the
should discontinue aspirin or other antiplatelet medications for 1
correct location.
week and anticoagulants for 4 days before the procedure. The
4. Use the curettes and cotton swabs to remove as much soft,
patient should be counseled about the risks for scarring, a possible
inflamed material as possible (Fig. 65-7; Fig. 65-4D). Remove as
need for sutures, the risk of recurrence and need for repeat excision,
much granulation tissue as you can with forceps (Fig. 65-8).
short-term swelling/bruising of eyelid, excessive bleeding, infection,
5. Using the Westcott conjunctival scissors and tissue forceps,
and, rarely, damage to the lacrimal drainage system resulting in
remove a small amount of the inflamed tarsal plate (the cartilage
chronic tearing. It will be important for the patient to remain
underneath), if necessary (Fig. 65-4E). Take care not to tent the
motionless during the procedure. The patient may experience some
deeper tissue, which can lead to inadvertent incision of the
discomfort and tearing with injection of the anesthetic.
underlying skin and cause a “buttonhole” defect. Again, avoid
damaging the eyelid margin.
Technique
Universal blood and body fluid precautions should be followed.
The clinician can achieve good access to the eye by sitting near the
top of the head. The patient should lie supine. Good lighting is
essential. Injection of the local anesthetic may make palpation of
the chalazion difficult, so it is helpful to use a skin marker before
injection.

1. Administer several drops of a topical ophthalmic anesthetic.

Then inject 2% lidocaine with epinephrine through the skin,
infiltrating the area where the chalazion clamp is to be applied
(Fig. 65-4A).
2. Place a chalazion clamp over the chalazion, with the open side
inside the eyelid (Fig. 65-4B). Avoid damaging the eyelid margin. Figure 65-5  After topical anesthetic drops are instilled, a chalazion
Tighten the clamp to achieve a firm grip on the eyelid, which clamp is used to stabilize and evert lid.

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430 EYES, EARS, NOSE, AND THROAT
Figure 65-6  Incising the chalazion using a no. 15 blade. Make an “X”
over the lesion.
Figure 65-7  Removing contents with a chalazion curette.
Figure 65-8  Removing granulation tissue with forceps (pickups).
Figure 65-9  Postoperative appearance after chalazion removal.
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6. Remove the chalazion clamp, which will likely lead to significant
bleeding because of the excellent vascularity of the eyelid. Apply
direct pressure with cotton swabs or gauze pads to achieve hemo-
stasis. This may take 5 to 10 minutes (Fig. 65-9). Once hemo-
stasis has definitely been achieved, apply an antibiotic–steroid
eye ointment and place a pressure patch on the eye (see Chapter
66, Corneal Abrasions and Removal of Corneal or Conjunctival
Foreign Bodies, Fig. 66-5, for a technique on pressure patching).
7. If a full-thickness eyelid defect is present, suture the outer skin
while taking care that the suture does not include the conjunc-
tival (inner) surface of the eyelid; this would cause a great deal
of irritation and possibly a corneal abrasion. If damage to the
lacrimal punctum or canaliculus occurs inadvertently, promptly
refer the patient to an ophthalmologist.
8. Beware of recurrent or multiple chalazia in older patients, espe-
cially with associated ocular inflammation. This could represent
sebaceous cell carcinoma, which is very aggressive and not always
noted on pathologic examination of an excised chalazion. If a
presumed chalazion does not behave as expected after excision,
particularly in an elderly patient, sebaceous cell carcinoma
should be suspected even if the initial pathology report is nega-
tive. In that situation, the patient should be referred to an
ophthalmologist.
Postprocedure Patient Education
The patient may remove the patch the evening after the procedure.
Tell the patient that he or she can expect a large amount of clotted
blood and mattering of the eyelid. The patient should then begin
to apply an antibiotic eye ointment (e.g., erythromycin) in the eye
twice a day until judged “back to normal.” If the eyelid begins to
bleed again, the patient should apply pressure until it stops, and
should seek medical attention if the bleeding does not stop. If sutures
were placed, they should be removed in 5 days.
HORDEOLUM
Medical Management
If less severe and not yet “pointing,” the hordeolum may be treated
with frequent warm compresses and an oral antibiotic directed
against Staphylococcus. In fact, most hordeola respond to this man-
agement, with spontaneous drainage and resolution occurring in 5
to 7 days. However, if the patient is being treated medically, he or
she should be watched closely in case the need for incision and
drainage develops.
Indications for Incision and Drainage
• Hordeolum that fails medical management (Fig. 65-10)
• Hordeolum causing significant pain
• Hordeolum with significant localized accumulation of pus
• Previous or current eyelid cellulitis associated with hordeolum
Figure 65-10  Hordeolum of upper lid.
 65  ——  CHALAZION AND HORDEOLUM 431

Contraindications to Incision and Drainage

If the hordeolum is located near the lacrimal punctum (i.e., located
nasal to the medial canthus), refer the patient to an ophthalmologist
because of the risk of damaging the lacrimal drainage system.

Equipment
• Mask and goggles to follow universal blood and body fluid
precautions
• Topical ophthalmic anesthetic drops (e.g., tetracaine)
• Alcohol pads
• Local anesthetic for injection, 2% lidocaine with epinephrine,
3-mL syringe, 30-gauge needle
• Nonsterile gloves
• Scalpel (no. 11 blade)
• Cotton swabs
• 4 × 4 gauze pads
• Tongue blade or metal elevator
Preprocedure Patient Preparation
Unless the patient is at high risk of cardiovascular events, he or she
should discontinue aspirin or other antiplatelet medications for 1
week and anticoagulants for 4 days before the procedure (although it
is usually necessary to perform the procedure without much advanced
planning). The patient should be counseled about the risks of scar-
ring, recurrence, and need for repeat incision and drainage, short-
term swelling/bruising of eyelid, excessive bleeding, spread of
infection, and, rarely, damage to the lacrimal drainage system result-
ing in chronic tearing. It will be important for the patient to remain
motionless during the procedure. The patient may experience some
discomfort and tearing with the injection of local anesthetic.
Figure 65-12  Stabilizing the hordeolum with a chalazion clamp.
4. If a full-thickness eyelid defect is present, do not suture the skin
because of the presence of acute bacterial infection. Consider
appropriate systemic antibiotic therapy for significant cellulitis of
the eyelid. If damage to the lacrimal duct occurs inadvertently,
promptly refer the patient to an ophthalmologist.
Postprocedure Patient Management
If the eyelid begins to bleed again, the patient should apply pressure
until it stops and should seek medical attention if he or she is having
difficulty controlling the bleeding. The patient will be given an oral
antibiotic (with good coverage for Staphylococcus), and should be
seen the next day. He or she may need to be seen daily for several
days after the procedure until it is evident that the cellulitis is resolv-
ing and that pus is not reaccumulating. The patient should make an
appointment in 2 to 3 weeks to further assess healing. It may take
several weeks for the swelling and tissue distortion to return to
normal.

Technique SAMPLE OPERATIVE REPORTS

Universal blood and body fluid precautions should be followed. The See sample operative reports online at www.expertconsult.com.
hordeolum will point either internally or externally and should be
incised from whichever surface allows the best access to the collec-
tion of pus (Fig. 65-11A). CPT/BILLING CODES
1. Administer several drops of topical ophthalmic anesthetic. Then For chalazion excision
administer 2% lidocaine with epinephrine through the skin, infil- 67800 Excision of chalazion, single
trating the area around the hordeolum. (Remember that anes- 67801 Excision of chalazion, multiple, same lid
thesia is more difficult to obtain in the presence of inflammation.) 67805 Excision of chalazion, multiple, different lids
A tongue blade or metal elevator can be inserted behind the lid
to protect the eye (Fig. 65-11B). It may be helpful to stabilize For incision and drainage of hordeolum
the hordeolum and lid with a chalazion clamp (Fig. 65-12). 67700 Blepharotomy, drainage of abscess, eyelid
2. Use a no. 11 scalpel blade to make an incision into the hordeo-
lum until pus is obtained, taking great care to avoid a through-
and-through eyelid defect or injury to the eyelid margin or eye. ICD-9-CM DIAGNOSTIC CODES
If significant cellulitis is present, it may be prudent to send a 373.2 Chalazion
sample of the pus for culture and sensitivity testing. 373.11 Hordeolum, NOS or external
3. After the pus is expressed (Fig. 65-13), apply direct pressure with 373.12 Hordeolum, internal
gauze pads to achieve hemostasis. This may take 5 to 10 minutes.
An eyepatch is not necessary.

B
A
Figure 65-11  Hordeolum excision. A, Hordeolum pointing externally.
B, Incision and drainage of external hordeolum, with a tongue blade or metal Figure 65-13  Incising the hordeolum: acute infection and drainage are
elevator protecting the eye. evident.

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432 EYES, EARS, NOSE, AND THROAT

PATIENT EDUCATION GUIDES RxMed: Illness Information. Available at http://www.rxmed.com/b.main/

b1.illness/b1.illness.html.
See the patient education and consent forms online at www. University of Maryland Health Center: Chalazions and styes. Available at
expertconsult.com. http://www.health.umd.edu/Library/Handouts/Chalazion805.pdf.

ACKNOWLEDGMENT For Clinicians

The editors wish to recognize the contributions by Lewis E. Mehl,
MD, PhD, to this chapter in a previous edition of this text.
SUPPLIERS
(Any medical instrument supplier can provide the necessary equip-
ment. See contact information online at www.expertconsult.com.)
Accutome
Storz (Bausch and Lomb)
ONLINE RESOURCES
For Patients
Medem: Medical Library. Available at http://www.medem.com/medlb/
article_detaillb.cfm?article_ID=ZZZBDDQNPGE&sub_cat=37.
Bessette M: Hordeolum and stye. Available at www.emedicine.com/EMERG/
topic755.htm.
Fansler JL, Schraga ED, Santen S: Chalazion. Available at www.emedicine.
com/EMERG/topic94.htm.
BIBLIOGRAPHY
Jacobs PM, Thaller VT, Wong D: Intralesional corticosteroid therapy of
chalazion: A comparison with incision and curettage. Br J Ophthalmol
68:836–837, 1984.
Langston DP: Manual of Ocular Diagnosis and Therapy, 6th ed. Philadel-
phia, Lippincott Williams & Wilkins, 2008.
Neff AG, Carter KD: Benign eyelid lesions. In Yanoff M, Duker JS (eds):
Ophthalmology, 2nd ed. St. Louis, Mosby, 2004, pp 698–710.
Usatine RP: The Color Atlas of Family Medicine. New York, McGraw-Hill,
2009.

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