aka Ophthalmology Befuddler 003
It’s Saturday night and a 28 year-old man presents to the emergency department with a lump on his eyelid. He says his fiance forced him to come, because they are getting married in 2 weeks and his future wife doesn’t want him looking like a goggle-eyed monster…
Photo by McBill (click on image for link)
Questions
Q1. What is the likely diagnosis?
Either a chalazion or a hordeolum (stye).
Q2. What is a hordeolum?
A stye, which is an eyelid lump resulting from acute infection; usually Staphylococcus.
There are two types:
- external — an abscess of one of the glands of Zeis on the lid margin.
- internal — an abscess of a meibomian gland.
Q3. What is a chalazion?
An area of focal inflammation within the eyelid tarsus secondary to obstruction of a meibomian gland. It is not an infective process and is sometimes called a meibonian gland cyst or lipogranuloma.
Check out this video at RootAtlas.com to see the mother of all chalazions…
Q4. Describe the management of chalazions and styes — and how do they differ?
They are generally clinically indistinguishable – both are acute or chronic eyelid lumps associated with tenderness and eyelid swelling. If it’s particularly hot and red it may be more likely to be a stye/ hordeloum.
They are managed in much the same way:
- Warm compresses (e.g. 10 min qid) are the mainstay of treatment. The lump usually resolves within a week or so.
- The Will’s Eye Manual suggests treating with topical antibiotics if there is blepharitis or a draining lesion, and if severe consider treating with oral antibiotics (e.g. doxycycline 100mg bd, has both antibacterial and anti-inflammatory actions).
- The Australian Therapeutic Guidelines suggests oral flucloxacillin (or cephalexin) for 5 days for internal hordeolums (styes).
- Lesions that do not resolve over a month or so should be reviewed by an ophthalmologist and may be incised and drained.
Check out Mel Herbert’s EMRAP.TV summary of this condition and his own experience as a long suffering victim of this terrible affliction… He has some nice tips for using a spoon as a ‘warm compress’ device as well as some great clinical pics.
Q5. What potentially nasty conditions may be the cause of a chronic eyelid lump?
Look for signs of inflammation, distortion and skin ulceration.
Don’t forget about these bad boys:
- basal cell carcinoma
- squamous cell carcinoma
- sebaceous gland carcinoma
- others such as malignant melanoma, lymphoma, sweat gland carcinoma, and metastases.
References
- Ehlers JP, Shah CP, Fenton GL, and Hoskins EN. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease (5th edition). Lippincott Williams & Wilkins, 2008.
- Marx JA, Hockberger R, Walls RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th edition (2009) Mosby, Inc. [mdconsult.com]
- NSW Statewide Opthalmology Service. Eye Emergency Manual — An illustrated Guide, 2007. [link to free pdf]
- Therapeutic Guidelines (Australia) [subscription required]
About Chris Nickson
Thanks dymphnasis. The histories in the case-based Q and As are generally fictionalised accounts of real encounters. This particular one, I actually embellished to make it seem MORE urgent… Glad you enjoyed it.