Benign Eyelid Disorders
Benign eyelid disorders are common eyelid conditions that are usually non-sight-threatening.
This updated UKMLA guide covers the main benign eyelid disorders: blepharitis, stye (hordeolum), and chalazion (meibomian cyst) – causes, risk factors, symptoms, diagnosis, and management.
Blepharitis
Blepharitis is an inflammatory, often bilateral, condition primarily affecting eyelid margins.
Causes and Risk Factors
| Type | Definition | Causes |
|---|---|---|
| Anterior blepharitis | Inflammation affecting the anterior eyelid margin, including the base of the eyelashes | 2 main causes:
|
| Posterior blepharitis | Inflammation affecting the posterior eyelid margin, which contains the meibomian glands | Usually associated with meibomian gland dysfunction, causing altered oily secretions and tear film instability |
Blepharitis is commonly associated with:
- Dry eye disease
- Including medications that can cause dry eye (e.g. anticholinergics, antihistamines, TCA)
- Dermatological conditions
- Seborrhoeic dermatitis (coexists with up to 95% of cases of seborrhoeic blepharitis)
- Rosacea (27-51%)
- Atopic dermatitis (eczema)
- Psoriasis
- Isotretinoin is associated with a significant increase in colonisation of the conjunctiva with Staphylococcus aureus, blepharitis, and a disruption in tear function
Clinical Features and Diagnosis
Blepharitis is primarily a clinical diagnosis.
Symptoms of blepharitis are typically bilateral
- Soreness, burning, itching, and crusting of the eyelids
- Worse in the morning
- Exacerbating factors include wind, makeup, and contact lens use
- Often co-exists with
- Dry eye disease (keratoconjunctivitis sicca)
- Seborrhoeic dermatitis
- Rosacea
Signs of blepharitis vary depending on the type and cause:
| Anterior staphylococcal blepharitis | Anterior seborrhoeic blepharitis | Posterior blepharitis |
|---|---|---|
In more severe cases:
Can predispose to stye (hordeolum) |
|
Signs of meibomian gland dysfunction:
Can predispose to chalazion (meibomian cyst) |
Severe or chronic blepharitis can occasionally lead to eyelid thickening and scarring, which may contribute to entropion or ectropion.
Blepharitis can contribute to dry eye disease, particularly through tear film instability and increased tear evaporation.
Management
See the Red Eye Referral article for indications to refer to ophthalmology.
1st line management is conservative to facilitate symptom resolution and prevent recurrence:
| Conservative eyelid measures | Eyelid hygiene:
Warm compress:
For those with posterior blepharitis, also advise on eyelid massage
|
| Patient education | Explain the chronic nature of blepharitis and the need for ongoing treatment
|
| Manage any associated conditions | For dry eye disease:
For rosacea, see the Rosacea article. For seborrhoeic dermatitis, see the Seborrhoeic Dermatitis article. |
2nd line management should be considered if conservative eyelid measures are ineffective:
- Anterior blepharitis → consider topical antibiotics (e.g. chloramphenicol ointment) to be rubbed into the lid margin
- Posterior blepharitis associated with rosacea → consider an oral tetracycline (e.g. doxycycline), see the Rosacea article for more information
If primary care treatment is ineffective, refer to ophthalmology.
Stye (Hordeolum)
A stye, also known as hordeolum, is an acute, localised infection or inflammation of the apocrine or sebaceous glands of the eyelid
- Plural of stye = styes
- Plural of hordeolum = hordeola
Causes and Risk Factors
Most commonly caused by a staphylococcal infection
Risk factors:
- More common in adults
- Poor eyelid hygiene
- Chronic blepharitis
- Rosacea
- Immunosuppression (e.g. diabetes)
- Hypercholesterolaemia (may increase the risk of sebaceous gland blockage)
Clinical Features and Diagnosis
Stye is primarily a clinical diagnosis.
Usually, an acute onset of unilateral:
- Tender eyelid lump
- Excessive tearing
- Local redness of the eye and eyelid
Signs vary, depending on the type of stye:
| External stye (more common) | Internal stye |
|---|---|
Inflammation of the eyelash follicle and its associated gland of Zeis or Moll:
|
Inflammation of a meibomian gland
|
Most styes are self-limiting, with symptoms resolving within 5-7 days.
Possible complications:
- Infective conjunctivitis
- Cellulitis (may develop into periorbital cellulitis, and rarely orbital cellulitis) (see the Periorbital and Orbital Cellulitis article for more information)
- Persistent internal stye may develop into a chalazion (meibomian cyst) – see below
Management
See the Red Eye Referral article for indications to refer to ophthalmology.
Reassure the patient that styes are usually self-limiting and rarely cause serious complications
Give self-care advice:
- Apply warm compress (e.g. clean flannel rinsed with hot water) to the closed eyelid for 5-10 min, 2-4 times daily, until the stye resolves
- Avoid using eye makeup or contact lenses until the area has healed
- Avoid puncturing the stye as this could further aggravate and spread the infection or cause an eye injury
For a painful external stye, consider the following (if expertise and facilities are available in primary care):
- Plucking the eyelash from the infected follicle (to facilitate drainage)
- Incision and drainage of the stye using a fine, sterile needle
Antibiotics are not routinely indicated for the management of a stye
- Although styes are usually caused by Staphylococcus aureus, they are typically localised and self-limiting, and antibiotics may not penetrate well in the presence of a blocked / inflamed gland
Only consider offering a topical antibiotic (e.g. chloramphenicol drops or ointment) if there is copious mucopurulent discharge.
If the stye does not improve or resolve with primary care management, refer to an ophthalmologist for further assessment and management.
Chalazion (Meibomian Cyst)
A chalazion, also known as a meibomian cyst, is a chronic, localised, non-infective inflammatory granuloma caused by blockage of a meibomian gland
- Plural of chalazion = chalazia
- Plural of meibomian cyst = meibomian cysts
Causes and Risk Factors
A chalazion may occur spontaneously
Risk factors:
- Follow an acute internal stye
- Chronic blepharitis
- Seborrhoeic dermatitis
- Rosacea
- Diabetes
- Pregnancy
- Hypercholesterolaemia
Clinical Features and Diagnosis
Chalazion is primarily a clinical diagnosis.
Typical presentation:
- Slow-growing, firm lump on the eyelid
- More common on the upper than the lower lid
- Painless (may be a little tender initially but settles rapidly)
A stye is usually acute and painful.
A chalazion is usually gradual, chronic and painless.
Possible complications:
- A large chalazion can cause visual disturbances (from mechanical ptosis or direct contact with the cornea)
- Chronic skin changes
- Rarely, it can become secondarily infected
Management
See the Red Eye Referral article for indications to refer to ophthalmology.
Reassure the person that meibomian cysts usually resolve within 6 months of conservative management
Give self-care advice:
- Apply warm compress (e.g. clean flannel rinsed with hot water) to the closed eyelid for 5-10 min, 2-4 times daily, until the chalazion resolves
- Avoid using eye makeup or contact lenses until the area has healed
If the meibomian cyst does not resolve within 6 months or is recurrent → refer to ophthalmology to consider:
- Invasive treatment (e.g. incision and curettage, intralesional steroid injections)
- Further investigations (e.g. biopsy) to rule out eyelid cancer or other serious conditions
There is no role for antibiotics in chalazion.