Chalazion & Hordeolum

The eyelid margin contains meibomian glands within the tarsal plate (secreting the oily component of the tear film) and glands of Zeis and Moll at the base of the eyelashes. Chalazion and hordeolum both arise from these glands but differ fundamentally: chalazion is chronic, sterile, granulomatous inflammation from obstructed meibomian (or Zeis) gland secretion, while hordeolum is an acute, typically staphylococcal infection of an eyelid gland.¹

A chalazion develops when a meibomian or Zeis gland duct becomes obstructed, causing retained lipid-rich secretion to leak into surrounding tarsal tissue and provoke a granulomatous, lipogranulomatous inflammatory response — a non-infectious process. A hordeolum is an acute suppurative infection of a meibomian gland (internal hordeolum) or a gland of Zeis/Moll at the lash line (external hordeolum), producing the classic acute, painful presentation.

Chalazion presents as a slowly enlarging, painless, firm tarsal nodule. Hordeolum presents acutely with pain, redness, swelling, and tenderness, sometimes with a visible pustule.

Key differentials: sebaceous gland carcinoma masquerading as a recurrent/atypical chalazion (critical in older patients), preseptal or orbital cellulitis (more diffuse, systemic signs), congenital eyelid lesions in children, and insect bite reactions.

Diagnosis is primarily clinical based on lesion appearance, chronicity, and associated findings. Hordeolum/chalazion is an extremely common presenting complaint — in an 8-year military teleophthalmology review, it was the single most common diagnosis (39.3% of cases), more common than viral conjunctivitis (20.3%).² Biopsy is warranted for any recurrent, atypical, or non-resolving lesion to exclude malignancy.

No single universally agreed treatment of choice exists given the range of effective options.¹ First-line conservative measures include warm compresses, lid hygiene, and topical antibiotic ointment with or without corticosteroid.¹ Persistent chalazia are treated with intralesional corticosteroid injection, with incision and curettage reserved for lesions failing both conservative treatment and steroid injection.¹ A small pilot study found oral probiotics alongside conservative treatment shortened resolution time for small chalazia, though this remains preliminary; medium/large chalazia did not respond to conservative treatment with or without probiotics.³

• Chalazion is chronic/sterile; hordeolum is acute/infectious — this distinction guides urgency and treatment
• Hordeolum/chalazion is extremely common, accounting for the largest share of consultations in some cohorts²
• Stepwise treatment (conservative → steroid injection → incision/curettage) remains standard given no single universal treatment of choice¹
• Any recurrent/atypical chalazion in an older patient warrants biopsy to exclude sebaceous gland carcinoma
• Common pitfall: proceeding directly to surgery without first attempting conservative measures
• Common pitfall: overemphasizing small pilot study findings (e.g., probiotics) as established recommendations³