Journal of Pediatric Ophthalmology and Strabismus

Eye to Eye 

Management of Recurrent Chalazia

Dawn N. Duss, MD; A. Paula Grigorian, MD; Norman B. Medow, MD

Abstract

Wagner: We frequently encounter children in the 3- to 5-year old age group who have multiple, often bilateral, chalazia that run a protracted course and are usually referred to us following initial attempts at treatment by a primary care physician. An example would be a 4-year-old cooperative child with multiple chalazia whose parent wants to get this taken care of. How would you treat this child?

Medow: Management of chalazia, especially recurrent chalazia, is not easy. First, I look at the eyelids to make sure there is no blepharitis or obvious reason for the chalazia to occur. I seldom excise chalazia unless they close the eyelid completely or give the child a large degree of astigmatism. If the chalazion is large, I will excise. I don’t use steroid injections in children, although I have in young adults. If it’s really serious, I will use an oral antibiotic. But most of the time I tell the parents that this is not serious and it’s going to clear up eventually.

Wagner: Dr. Grigorian, do you manage them any differently?

Grigorian: I usually use warm compresses, and I prefer to use a rice bag because it holds heat longer. I don’t use antibiotics unless everything else fails, and then it is for their anti-inflammatory properties. For children I use erythromycin at a small dose four times a day and I taper it gradually over weeks. I also like to add 1 teaspoon of flax seed oil to their diet. Children may be teased about chalazia so I may operate if the chalazion has been present for longer than a month with treatment.

Wagner: Please describe the rice bag treatment.

Grigorian: I tell the parents to put some uncooked rice in a clean, new sock and microwave it for up to 20 to 30 seconds, then apply it to the child’s eye for approximately 10 minutes, ideally four times a day.

Medow: Any time you are heating something in a microwave, it’s important to caution the parents to test it with their ungloved hand before placing it on the child’s eye. Otherwise a severe burn could result.

Wagner: Dr. Duss, would you add anything to the initial management already described?

Duss: I have used Restasis (Allergan Inc., Irvine, CA) on several occasions, especially if there is a tear film abnormality or in cases of phlyctenular disease, because there’s evidence to support this as a grade 4 hypersensitivity reaction responsive to cyclosporin. I also think there’s a role for the oral antibiotic with a slow taper, either erythromycin in children younger than 8 years or doxycycline in those older than 8 years.I think recurrent chalazia are precursors for chronic blepharokeratoconjunctivitis, a condition that leads to corneal sequelae, scarring, and astigmatism and therefore amblyopia. I also consider external signs when determining whether to treat more aggressively. There has been discussion about rosacea being more common in children than previously thought, so I will look for facial flushing and erythema, although the ocular manifestations may actually present before the skin manifestations and these children may benefit from oral antibiotics.

Wagner: One of the hot topics in ophthalmology is meibomian gland disease. Do you believe there is a relationship between this and chalazia in children?

Duss: Yes, I think there’s an association with chalazia and with corneal sequelae and keratoconjunctivitis. Studies in London and Japan demonstrated a higher risk of corneal involvement with posterior blepharitis/meibomian gland dysfunction. These children had chronic scarring and visual loss.

Wagner: What findings on your clinical examination would you expect to see in a child who has meibomian gland dysfunction?

Duss: Pouting and…

Wagner: We frequently encounter children in the 3- to 5-year old age group who have multiple, often bilateral, chalazia that run a protracted course and are usually referred to us following initial attempts at treatment by a primary care physician. An example would be a 4-year-old cooperative child with multiple chalazia whose parent wants to get this taken care of. How would you treat this child?

Medow: Management of chalazia, especially recurrent chalazia, is not easy. First, I look at the eyelids to make sure there is no blepharitis or obvious reason for the chalazia to occur. I seldom excise chalazia unless they close the eyelid completely or give the child a large degree of astigmatism. If the chalazion is large, I will excise. I don’t use steroid injections in children, although I have in young adults. If it’s really serious, I will use an oral antibiotic. But most of the time I tell the parents that this is not serious and it’s going to clear up eventually.

Wagner: Dr. Grigorian, do you manage them any differently?

Grigorian: I usually use warm compresses, and I prefer to use a rice bag because it holds heat longer. I don’t use antibiotics unless everything else fails, and then it is for their anti-inflammatory properties. For children I use erythromycin at a small dose four times a day and I taper it gradually over weeks. I also like to add 1 teaspoon of flax seed oil to their diet. Children may be teased about chalazia so I may operate if the chalazion has been present for longer than a month with treatment.

Wagner: Please describe the rice bag treatment.

Grigorian: I tell the parents to put some uncooked rice in a clean, new sock and microwave it for up to 20 to 30 seconds, then apply it to the child’s eye for approximately 10 minutes, ideally four times a day.

Medow: Any time you are heating something in a microwave, it’s important to caution the parents to test it with their ungloved hand before placing it on the child’s eye. Otherwise a severe burn could result.

Wagner: Dr. Duss, would you add anything to the initial management already described?

Duss: I have used Restasis (Allergan Inc., Irvine, CA) on several occasions, especially if there is a tear film abnormality or in cases of phlyctenular disease, because there’s evidence to support this as a grade 4 hypersensitivity reaction responsive to cyclosporin. I also think there’s a role for the oral antibiotic with a slow taper, either erythromycin in children younger than 8 years or doxycycline in those older than 8 years.I think recurrent chalazia are precursors for chronic blepharokeratoconjunctivitis, a condition that leads to corneal sequelae, scarring, and astigmatism and therefore amblyopia. I also consider external signs when determining whether to treat more aggressively. There has been discussion about rosacea being more common in children than previously thought, so I will look for facial flushing and erythema, although the ocular manifestations may actually present before the skin manifestations and these children may benefit from oral antibiotics.

Wagner: One of the hot topics in ophthalmology is meibomian gland disease. Do you believe there is a relationship between this and chalazia in children?

Duss: Yes, I think there’s an association with chalazia and with corneal sequelae and keratoconjunctivitis. Studies in London and Japan demonstrated a higher risk of corneal involvement with posterior blepharitis/meibomian gland dysfunction. These children had chronic scarring and visual loss.

Wagner: What findings on your clinical examination would you expect to see in a child who has meibomian gland dysfunction?

Duss: Pouting and capping of the meibomian gland, meibomian gland hypertrophy, telangiectasia along the eyelid margin, or indentations along the eyelid margin can be signs of chronic inflammation.

Wagner: Dr. Grigorian, you mentioned the use of flax seed oil. Is that because it is an omega 3 fatty acid?

Grigorian: Yes. It helps to liquefy the meibomian gland secretion so they don’t get the pouting that Dr. Duss mentioned. Meibomian gland function improves and there is less recurrence of the chalazia.

Wagner: How do you tell people to use the flax seed oil?

Grigorian: There are capsules that can be swallowed or broken and sprinkled on food, or they can use the ground seeds in food so the child doesn’t have to swallow a pill.

Duss: I think there’s also a liquid form.

Grigorian: Yes, there are many different products.

Medow: I agree there is an association between chalazia and chronic meibomian gland disease, eyelid margin disease, and corneal or conjunctival disorders, but I think only a small percentage of children are affected. So you should look for signs that indicate more aggressive treatment in specific cases, but most of the time they clear up eventually without treatment.

Duss: I agree. I do treat surgically more often than Dr. Medow and I think the age of the child makes a difference. I am more likely to treat surgically in teenagers. I think triamcinolone injections are helpful, especially if it’s an external presentation or it’s right along the eyelid margin. Those are not amenable to incision and curettage, so injection of triamcinolone works well.

Medow: The original studies for injections for chalazia were done in the military, primarily on healthy men under local anesthesia, and achieved good results. But whether you inject around the chalazia or into the chalazia, it’s going to hurt a bit. A cooperative teenager will tolerate it, but a younger child will not without anesthesia. Is that how you would do it?

Duss: I bring younger children to the operating room and use general anesthesia.

Grigorian: I think it’s important to take every case on an individual basis. Every child is different and every chalazion is different. Teenagers want to look like their friends and may want to get rid of it right away, whereas younger children may be willing to wait.

Medow: There are psychosocial issues in teenagers with chalazia and I may modify my approach in those cases, but overall I think chalazia is just a nuisance to deal with.

Duss: Some parents just want to make sure the child’s vision is safe and won’t consider general anesthesia. Other parents are more aggressive about the option of surgery.

Wagner: I find it easier to operate under general anesthesia even in an older cooperative child. I think the injection of the anesthetic agent sometimes distorts the anatomy around the chalazion and there might be recurrence because perhaps I didn’t excise the capsule completely. I also agree with Dr. Duss in that the most difficult cases are those associated with rosacea or possibly staph blepharitis. Dr. Medow, how do you respond to the common question asked by the parent of why is my child getting these now?

Medow: If there is no obvious disorder, I just tell them that some children have gland congestion issues and we don’t have a good answer as to why. We know that it’s not serious, it’s not going to impair their vision or their health, and it can be treated.

Wagner: I wonder if diet plays a role in causing chalazia and adding flax seed oil or omega 3 fatty acids could help.

Duss: There may be an HLA association. The Japanese study I mentioned did find an HLA, A26, and B35 association. So it may be genetic. I have noticed that Asian and Middle Eastern races seem to be more affected.

Wagner: The condition does come up frequently and it does bother the parents and children perhaps out of proportion to what we would normally expect, but I expect that’s because it’s noticeable. Thank you all for participating.

Authors

Dawn N. Duss, MD, is from Nemours Children’s Clinic, Jacksonville, Florida.

A. Paula Grigorian, MD, is from University Hospitals Rainbow Babies & Children’s Hospital, Cleveland, Ohio.

Norman B. Medow, MD, is from Montefi ore Hospital Medical Center and Children’s Hospital at Montefiore (CHAM), Bronx, New York.

Moderator: Rudolph S. Wagner, MD

This Eye to Eye session was conducted on Sunday, March 25, 2012, during the annual meeting of the American Association for Pediatric Ophthalmology & Strabismus.

Drs. Duss, Grigorian, and Medow have no financial or proprietary interests in the materials presented herein. Dr. Wagner is on the speaker’s bureau of Alcon Laboratories.

10.3928/01913913-20120720-03

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