The patient’s unmet needs (PUNs)
‘I’ve got that stye again,’ says your next patient. ‘I think I’m going to need some more of that antibiotic cream.’ A glance at his notes shows he has been treated with chloramphenicol eye ointment for what has variably been described as a stye or blepharitis. Examination reveals a diffuse swelling of his lower eyelid, which is slightly tender, and gentle eversion of the lid reveals a Meibomian cyst. You explain the problem to him.
‘Is there anything I can do to get rid of it?’ he asks. ‘Or will it have to be cut out? I don’t like the idea of an operation.’
The doctor’s educational needs (DENs)
How can GPs distinguish a Meibomian cyst from a stye, especially when it’s infected?
The site of maximum inflammation is the distinguishing feature. An inflamed cyst is within the eyelid – an exquisitely tender subcutaneous lump may be palpable approximately 3mm distal to the eyelid margin, often in association with swelling of the eyelid. Inflammation and tenderness usually involve the drainage duct, which opens on to the inner lid margin (internal hordeleum).
A stye is inflammation of an eyelash follicle or surrounding glands and causes redness and swelling at the front of the lid, at the eyelash base near the junction of the eyelid and skin (external hordeleum). It is often caused by staphylococcal infection.
What other differential diagnoses should the GP consider?
Other eyelid lumps in this age group are usually benign skin lesions such as fibroadenoma or sebaceous cyst. Beware of the very rare but aggressive sebaceous gland carcinoma, which accounts for 1-5% of all eyelid malignancies and has up to 20% mortality at five years. It can present as a firm, slowly enlarging, lump mimicking regrowth of an excised chalazion, so any recurrence after surgery must be referred for a specialist opinion.
When presented with a patient with an apparent chalazion that hasn’t already been excised, local eyelash loss next to the lesion is important, as is the apparent continued growth of an excised chalazion. Anything atypical should be regarded as suspicious and sent for specialist review. Biopsy of a typical primary chalazion is not usual practice.
What is the prognosis? How likely is it to resolve on its own?
Reports indicate that 25% of lesions may resolve in three to six months without specific measures.1 With conscientious daily heat and massage, spontaneous cure rate improves up to 50%, especially with small cysts.2 Larger cysts may remain indefinitely.
What self-help measures should the GP advise? And how effective are these?
In the acute stage, twice-daily hot compresses and gentle massage of the obstructed gland towards the lashline may resolve the obstruction, with spontaneous discharge of retained secretions. But when the lipogranuloma has formed and is no longer tender, massage is less successful, although one study reported around 90% resolution with non-surgical measures overall.3
Does antibiotic treatment help either in the infected stage or in terms of helping longer-term resolution?
Topical antibiotics are not indicated unless there is an abscess at the duct orifice. Rarely, spreading infection (usually staphylococcal) into neighbouring eyelid structures in the acute stage requires treatment with systemic broad-spectrum antibiotics.
At what point might referral be warranted? Is surgery the only effective treatment for persistent cysts?
After three months of non-painful cyst, despite conservative measures, other treatments should be considered. Where there is pressure to improve cosmesis – for instance, the chalazion has ulcerated through the skin, or a large cyst is distorting the cornea in a young child (risk of amblyopia) – intervention should be considered sooner.
An operation is usually performed as a minor procedure. After local anaesthetic infiltration, the eyelid is everted using a guarded chalazion clamp and a small incision is made into the cyst from the conjunctival surface and the contents curetted out. The operation takes about 10 minutes. Antibiotic ointment and an eye pad are applied and left in place for several hours to reduce bruising. The patient is warned to expect periocular bruising with bloodstained tears for a few days. Cyst remnants may take several weeks to reabsorb.
There is no 100% effective treatment. Steroid injection around or into the cyst may successfully treat 60-85% of those persisting at three months. Because of reported loss of skin pigment at the injection site, a conjunctival approach is recommended.
After instilling anaesthetic eyedrops, the lid is everted with a cotton bud and 0.2ml of 10mg/ml triamcinolone is injected around the chalazion using an insulin syringe and fine needle. Expect the cyst to reduce in size over the next few days, with the option of re-injection at one week if the cyst persists. Follow-up has reported less pain and inconvenience in those treated by steroid injection, and equal satisfaction to surgery.4 Trials comparing the treatments recommend incisional surgery for larger cysts.
Benign granuloma of oil-producing gland of the eyelid
Blockage of gland duct by thick oil or keratin causes gland rupture and lid inflammation
Common lid lesion associated with blepharitis at any age
Acute inflammatory onset of red, swollen lid settles to leave painless lump in eyelid
Heat and gland massage in acute phase, intralesional steroid for smaller lesions, incision and curettage for persistent or large cysts
Dr Gilli Vafidis and Dr Vickie Lee are consultant ophthalmic surgeons at North West London Hospitals NHS trust.
Find more information on managing eye conditions in general practice here.