History and exam
Key diagnostic factors
common
acute pain of eyelid only
Patients most commonly complain of acute, unilateral eyelid pain of either the upper or lower lid. Pain of the globe is not present. Eyelid pain is typically located at the lid margin in an external hordeolum, or somewhat more diffuse, pointing towards the tarsal conjunctiva, in an internal hordeolum.
Patients might describe eye pain, but on further and more detailed questioning complain of pain in the eyelid only. Pain involving the globe, especially with movement of the eye, should raise the concern for orbital cellulitis.
pustule at eyelid margin
On examination, patients with an external hordeolum typically have an easily identifiable pustule at the eyelid margin. Lack of a pustule at the margin with a painful lid should prompt the clinician to consider an internal hordeolum or chalazion.
pustule at tarsal conjunctiva
In contrast to an external hordeolum, patients with an internal hordeolum often have a pustule that is easily identifiable by everting the eyelid. The process for an internal hordeolum differs from an external hordeolum in that it involves the meibomian gland, which sits deeper in the tarsal plate.
palpable non-tender nodule
A chalazion has a well-defined, 2-8 mm diameter subcutaneous nodule in the tarsal plate.[6] This nodule is non-tender without associated pain or erythema.
lack of constitutional symptoms
Patients lack any constitutional or systemic symptoms, as the formation of styes and chalazia are localised processes.
lack of eye pain
Patients might describe eye pain, but on further and more detailed questioning complain of pain in the eyelid only. Pain involving the globe, especially with movement of the eye, should raise the concern for orbital cellulitis.
lack of intra-ocular pathology
The clinician may find minor conjunctival injection secondary to mechanical irritation or patient manipulation of the eye. However, careful examination should reveal no other pathology of the globe itself. Other findings within the eye or pain with range of motion of the eye should prompt the clinician to consider other diagnoses.
Other diagnostic factors
common
chronic swelling of eyelid
With more chronic lid swelling, the clinician must consider a chalazion. Patients often have a non-tender, palpable nodule away from the lid margin.
age 30-50 years
Adults are more likely to have hordeola and chalazia. Blepharitis and rosacea are more common in adults and are associated with hordeola. Increased viscosity of sebum in adults has been theorised to increase risk of chalazia.
uncommon
history of blepharitis and ocular rosacea
Both of these conditions create inflammation at the eyelid margin, which might potentially create mechanical obstruction of glands and a predisposition to infection.[8]
astigmatism and blurred vision
In chalazia, sometimes induced astigmatism (typically against the rule or oblique) can cause blurred vision. Induced astigmatism or hyperopia may cause change in refraction (particularly if large or in children). Large or multiple chalazia involving the whole upper eyelid carry the greatest risk of inducing a change in corneal topography. Large chalazia may also obscure vision or impact on eyelid closure.[6]
Risk factors
weak
age 30-50 years
Incidence in children is generally lower than in adults. Higher viscosity of sebum, a higher incidence of meibomian gland dysfunction, and higher incidence of rosacea in adults has been theorised to account for this difference.
blepharitis and ocular rosacea
Chronic inflammation at the eyelid margin probably results in a higher incidence of styes (hordeola) due to mechanical factors. Obstruction of ducts that drain meibomian and ciliary glands might lead to higher incidence of stasis and bacterial colonisation, which leads to hordeolum formation. Blockage of sebaceous drainage might also lead to increased incidence of chalazia.[2][4][6][7][8]
seborrhoeic dermatitis
elevated serum cholesterol
High levels of serum cholesterol may increase the risk of blockage to sebaceous glands of the eyelids, predisposing to styes and chalazia.[9]
diabetes mellitus
poor eyelid hygiene
Factors contributing to stye and chalazia include poor hygiene and contact lens care.[2]
ethnic origin
Hispanic, American Indian, and Asian people have higher rates of chalazia than other ethnic/ancestral groups. However, the increased risk of developing chalazia was not associated with an increase in the percentage of chalazia requiring surgery.[11]
tuberculosis
Although rare, extrapulmonary tuberculosis can affect the eye and surrounding orbital tissues. Eyelid tuberculosis may present as chronic blepharitis or recurrent chalazia.[12]
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