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Contents lists available at ScienceDirect

Disease-a-Month

journal homepage: www.elsevier.com/locate/disamonth

Common inflammatory and infectious

conditions of the eyelid ✩
Abigail A. Gordon, MD a, Dagmara J. Danek, DO b,
Paul O. Phelps, MD c,d,∗
a
Division of Internal Medicine, NorthShore University HealthSystem, Evanston, IL, United States
b
Division of Ophthalmology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, United States
c
Division of Ophthalmology, NorthShore University HealthSystem, Evanston, IL, United States
d
Department of Ophthalmology and Visual Science, University of Chicago, Chicago, IL, United States

a r t i c l e i n f o a b s t r a c t

Patients with infection or inflammation of the eyelid will of-

Article history: ten first present to their primary care physicians with symp-
Available online xxx toms such as redness, swelling, tearing, itchiness, or a foreign
body sensation. There are a variety of conditions that affect
Keywords:
the eyelid which can cause such symptoms, and the exam
Dry eye
and history can help a provider differentiate some of the
Chalazion
Hordeolum more common conditions. This article will provide a com-
Stye prehensive review of the background, diagnosis and manage-
Preseptal cellulitis ment of dry eye disease, chalazion, hordeolum (stye), and
preseptal cellulitis.
© 2020 Elsevier Inc. All rights reserved.

Introduction

Patients with infection or inflammation of the eyelid will often first present to their primary
care physicians. These patients may express discomfort, tearing, swelling, redness, a foreign body
sensation, itchiness or a combination of all of these symptoms. This article will cover the con-
ditions of dry eye, hordeolum (commonly known as a stye), chalazion, and preseptal cellulitis.

✩
Sources of Support and Disclaimers: None.
∗
Corresponding author at: NorthShore University HealthSystem, 2050 Pfingsten Rd., Ste. 280, Glenview, IL 60026,
United States
E-mail address: pphelps@northshore.org (P.O. Phelps).

https://doi.org/10.1016/j.disamonth.2020.101042
0011-5029/© 2020 Elsevier Inc. All rights reserved.

Please cite this article as: A.A. Gordon, D.J. Danek and P.O. Phelps, Common inflammatory and infectious conditions of
the eyelid, Disease-a-Month, https://doi.org/10.1016/j.disamonth.2020.101042
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Many of these cases can be treated by the primary care physician, though more severe presen-
tations warrant referral to an ophthalmologist.

Dry eye disease

Background: The tear film is composed of three layers: inner mucin, middle aqueous, and
outer lipid. Each of these layers is produced by a separate component of the eye. The goblet
cells, interspersed in the conjunctiva, are responsible for producing the mucinous layer of the
tear film.1 Vitamin A deficiency may lead to decreased goblet cells and mucin production. The
lacrimal gland produces the middle aqueous component of the tears. Some medications, such as
cyclosporine, aim to increase production of the aqueous layer. Meibomian glands are sebaceous
glands of the eyelids that secrete meibum, the lipid component of tear film. Meibum slows tear
film evaporation, maintains a clear optical surface, and serves as a barrier to protect the eye
from microbes and organic irritants such as dust and pollen.2 Dysfunction in any or all of these
layers can cause the symptoms of dry eye.
Dry eye disease is categorized into two main types: aqueous deficient and evaporative. Aque-
ous deficient dry eye can be due to impaired lacrimal gland function as a result of disease or
inflammation. Inflammatory conditions such as Sjogren’s syndrome, sarcoidosis, thyroid disease
or diabetes are potential causes of lacrimal gland dysfunction. In addition, HIV, hepatitis, CMV
infections, or toxins such as radiation can affect the lacrimal gland and may result in aqueous
deficiency.3 Evaporative dry eye disease is most commonly associated with meibomian gland
dysfunction (MGD), a chronic condition of the meibomian glands due to hyperkeratinization of
meibomian gland ductal epithelium.1 , 4
Risk factors for development of dry eye disease include older age, anterior blepharitis, con-
tact lens wear, female gender, decreased blinking, Sjogren’s syndrome, and hormonal irregulari-
ties.1 , 4 Populations of Asian descent have a higher prevalence of meibomian gland dysfunction.1
Patients with certain skin conditions, such as acne rosacea and seborrheic dermatitis, are more
likely to demonstrate meibomian gland dysfunction.
Patients with dry eye disease and MGD frequently present with chronic eye irritation and
discomfort. The complaints of ocular irritation, foreign body sensation, itching, burning, blurred
vision, dryness, or tearing are common.2 Patients with dry eye disease are also at risk of de-
velopment of hordeolum and chalazia.1 Symptoms may be constant or intermittent and may be
exacerbated by cold, wind, dry environments, or situations as sleeping with a fan. The patient
may describe temporal associations of symptoms, such as upon awakening or following periods
of concentration that result in less blinking (e.g., reading, watching TV, working in front of a
screen).
Exam: Clinical examination begins with a careful history of symptoms and concurrent dis-
ease since there are a variety of potential causes of dry eyes, some of which may be reversible.
Patients should be screened for the risk factors discussed above, including conditions that might
cause hormone changes such as menopause or pregnancy. Medications that are associated with
development of meibomian gland dysfunction should be noted, in particular, antiandrogens, hor-
mone therapy, antihistamines, antidepressants and retinoids.1 Any culprit medications should be
discontinued, if possible.
Patients who report significant symptoms of dry eye should be evaluated by an ophthalmol-
ogist for further workup. This examination will include measuring the blink rate, tear meniscus
height and tear break up time under a slit lamp. The ophthalmologist will additionally evaluate
for signs of MGD, which can be graded based on the induced secretion from the meibomian
glands. Patients with suspicious findings might also undergo a Schirmer and tear film osmolar-
ity testing, both of which can aid in specifying the diagnosis of eye disease. These measures are
useful in guiding treatment options.
Management: Management of dry eye is focused on symptomatic relief. Treatment is aimed
at supplementing tear production, slowing tear evaporation, reducing tear resorption, and reduc-
ing ocular surface inflammation. Initial treatment consists of conservative management, includ-

Please cite this article as: A.A. Gordon, D.J. Danek and P.O. Phelps, Common inflammatory and infectious conditions of
the eyelid, Disease-a-Month, https://doi.org/10.1016/j.disamonth.2020.101042
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ing supplementing tear production by applying regular artificial tears up to four times per day.2
If regular artificial tears do not provide sufficient symptomatic relief, then preservative-free ar-
tificial tears may be used as frequently as every hour. This type of artificial tear eliminates the
danger of corneal toxicity that may result from preservatives in regular artificial tears. Useful en-
vironmental alterations include decreasing use of air conditioning or heating, using a humidifier,
increasing blinking frequency, going on a contact lens holiday, and fitting a moisture chamber
into glasses to increase local humidity.
Punctal occlusion is an additional noninvasive intervention for reducing tear resorption. Punc-
tal plugs or cauterization seal off the tear ducts of the inner eyelids, which prevents tears from
draining. Punctal plugs are inserted in clinic and may be a temporary or semi-permanent treat-
ment for chronic dry eye, depending on the material used. Collagen plugs are temporary and
dissolve within a few weeks to months. Silicone plugs are expected to last for years, whereas
punctal cauterization is permanent.
Patients with meibomian gland dysfunction should practice good eyelid hygiene with warm
compresses, lid massaging, and lid washing.1 Warm compresses liquefy the hardened, backed-
up glandular secretions and, along with gentle massage, increase circulation in the meibomian
glands, thereby facilitating and increasing the quantity of secretions. These compresses should
be applied at least twice daily for 15 min at a time. Eyelid washing is encouraged, as many pa-
tients with meibomian gland dysfunction accumulate debris on their lashes. Baby shampoo can
be applied with a wash cloth or cotton pad to the lid margin, avoiding the ocular surface, and
thoroughly rinsed.2 In older patients with significant dandruff on the skin and eyelashes, as well
as typical signs of blepharitis, the physician should suspect Demodex infestation. A trial of tea
tree oil lid scrubs should be attempted in these patients as this has been shown to eradicate
Demodex. If severe MGD is present, systemic antibiotics may be considered. Although meibo-
mian gland dysfunction is not an infectious process, these antibiotics may reduce inflammation
and bacterial overgrowth, improving the symptoms of dry eye. Doxycycline, minocycline and
azithromycin are frequently used antibiotics.2
Newer treatments for MGD include Intense Pulsed Light (IPL) and LipiFlow R
. IPL uses pulses
of light to liquefy and release hardened secretions that have clogged the meibomian glands. A
specific protocol for treatment of MGD with IPL has been developed.5 This treatment reduces
telangiectasias, which secrete inflammatory mediators that surround the meibomian glands. Use
of this device requires significant training as there are risks to the pigmented tissues of the eye,
and so metal shields must be worn by the patient during treatment and dark goggles must be
worn by the provider. There is also some risk of damage to the eyelash follicles as IPL may
also be used for hair removal. LipiFlow R
is a device that attaches to the eyelids, heats up the
meibomian glands, and massages them for a 12-minute session. This treatment has been shown
to improve MGD and is generally very well tolerated.
Patients with lacrimal gland dysfunction may also be treated with cyclosporine emulsions
(e.g. Restasis), targeting the underlying inflammatory conditions that may contribute to dry eye.3
Patient compliance and counselling on long term use is important in patients on cyclosporine
compounds, as many patients become frustrated with lack of immediate results.3 Treatment
with vitamin A (retinyl palmitate) eye drops may also improve symptoms of dry eye syndrome.

Chalazion

Background: A chalazion is a lipogranulomatous inflammation of the sebaceous glands of

the eyelid.6 The Meibomian glands normally secrete oil through small pores located at the eye-
lid border, and obstruction of these pores results in pathology. Meibomian glands are twice as
numerous in the upper lid than in the lower, all embedded in the tarsal plate.7 Thus, patients
more commonly present with chalazia in the upper eyelid.
This condition can affect individuals of all ages; however, it tends to occur more often in the
younger age group who may prefer to avoid surgical intervention.8 Patients with chalazia may
have coexisting blepharitis or acne rosacea.11

Please cite this article as: A.A. Gordon, D.J. Danek and P.O. Phelps, Common inflammatory and infectious conditions of
the eyelid, Disease-a-Month, https://doi.org/10.1016/j.disamonth.2020.101042
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Fig. 1. Left upper eyelid chalazion. Note the location near the eyelid margin and lack of inflammatory signs. .

Exam: Patients with chalazia will present with a swollen mass at or above the margin of
the eyelid. (Fig. 1) The lesions can also be significantly edematous and may occasionally obscure
the patient’s vision.8 The initial presentation may mimic a preseptal cellulitis without a defined
mass noted by the examiner. Practitioners should inquire about systemic symptoms, such as
fever, which may raise suspicion of orbital cellulitis rather than chalazia.7
Management: Patients who present with a chalazia should first be instructed in good eye-
lid hygiene, as this practice can relieve the blockage of the Meibomian gland and allow for the
release of built up secretions. Patients should be instructed to place a warm compress onto the
lesion for 5–10 min at a time. Several commercial masks are available which make this process
simplified by allowing the patient to simply microwave their mask and place it on the eyelid
rather than using a clean towel or washcloth under warm water to repeatedly compress the
eyelid. These compresses should not be so warm as to burn the eyelids, as the skin at the eyelid
margin is sensitive.9 Patients should be instructed to repeat this process four to five times per
day.7 The eyelids should also be scrubbed with baby shampoo. With good adherence, patients
can have great success in treating the chalazion with simple conservative managemen;t9 how-
ever, patients should be counselled that conservative treatment does not always mean immedi-
ate resolution. Additional measures include systemic tetracycline for patients who have chronic
blepharitis. Some authors recommend waiting to refer patients until after one month of conser-
vative therapy before pursuing alternative treatments.7 However, if the chalazion persists after
two months, it is less likely to resolve with conservative therapies, and more invasive methods
such as incision and curettage or intralesional glucocorticoid injection should be considered.10
Recent studies have suggested that patients with primary and recurrent chalazia can be often
be successfully treated with triamcinolone acetate injections.11 Injections may be a good treat-
ment option for patients who are reluctant to have the lesion excised, however some potential
complications are associated with this treatment. More common risks include skin depigmen-
tation at the injection site, and more rare risks include inadvertent globe penetration as well
as retinal and choroidal vascular occlusion. To minimize the risk of skin depigmentation, many
practitioners prefer to inject with a subconjunctival approach rather than transcutaneous.11
Surgical treatments are available for patients who do not have resolution with conservative
measures, or in cases of larger lesions. Incision and curettage can be done in an office setting
by an ophthalmologist, who will utilize local anesthetic and an eyelid clamp before incising the
lesion and breaking up loculations. Both surgical management and triamcinolone injections have
been shown to have lower long-term recurrence rates than conservative therapy alone.8
In some cases, patients may present with an eyelid lesion similar in appearance to a cha-
lazion, but is actually a benign, premalignant or other malignant lesion. Some authors recom-
mend sending all chalazion excisions to pathology to verify the correct diagnosis. Patients with
true chalazion will have pathology consistent with a lipogranulomatous reaction, similar to gran-
ulomas seen in sarcoidosis or tuberculosis.6

Hordeolum

Background: A hordeolum is an inflamed oil gland on the margin of the eyelid. Unlike cha-
lazia, hordeola are usually caused by an infection. An internal hordeolum represents an infection

Please cite this article as: A.A. Gordon, D.J. Danek and P.O. Phelps, Common inflammatory and infectious conditions of
the eyelid, Disease-a-Month, https://doi.org/10.1016/j.disamonth.2020.101042
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Fig. 2. Right upper lid and right lower lid hordeolum. Note the associated erythema, excoriation of skin and edema.

of a Meibomian gland, while an external hordeolum represents an infection of a gland of Zeis.

(Fig. 2) An external hordeolum is known commonly as a stye.12 Most often Staphylococcus aureus
is responsible for the infection.7
Most cases of hordeola resolve without intervention, so patients do not always seek med-
ical treatment. Patients with blepharitis and rosacea are more likely to develop a hordeolum.
Like chalazia, hordeola can occur in any age group. Recurrence is very common, and patients
should be counselled that their styes may recur, usually due to failure of completely eliminating
bacteria.12
Exam: Patients with a stye will present similarly to chalazion. They will experience a red and
swollen round mass of the eyelid. The lesion is often tender to touch and usually appears sud-
denly, sometimes noticed upon awakening from sleep. These patients may report having experi-
enced similar lesions in the past. Similar to patients with a chalazion, these patients should not
report ocular signs of involvement. Visual acuity, intraocular pressures and extraocular move-
ments should all be within normal limits. If they are not, then the patient should be urgently
referred to an ophthalmologist.
Management: Treatment of hordeola is similar to that of chalazia. The infection is usually
self-limited, and patients tend to improve within a week.7 Use of warm compresses and conser-
vative management should be emphasized, as detailed previously in this article. In most cases
the abscess resolves in one to two weeks.12
Bacterial infection is the most common mechanism in hordeola, so treatment can also in-
clude use of topical antibiotics such as erythromycin 0.7 These topical antibiotics may serve to
both reduce the inflammation and treat the underlying bacterial infection.12 Patients who have
recurrent hordeola in the setting of rosacea or seborrheic dermatitis may respond to topical cor-
ticosteroid ointment. However, since topical steroids increase the risk of cataracts and increased
intraocular pressure, this should only be considered a temporary treatment.

Preseptal cellulitis

Background: Preseptal cellulitis refers to a cellulitis of the eyelid located in the preseptal
region. The orbital septum is a fibrous structure that is part of the anterior orbital connective
tissue framework which serves to contain orbital fat. It is useful anatomically because it forms a
border within the eyelid, such that infections can be divided into those with preseptal and those
with postseptal (orbital) involvement.13 Preseptal cellulitis has a generally favorable prognosis,
owing to the lack of involvement of the globe and orbit. These patients will commonly present
to their primary care providers prior to seeking care elsewhere.
Pediatric patients with preseptal cellulitis often have concurrent sinus infections, as spread
from the sinuses is the most common cause in children. Additional potential causes include
trauma, foreign bodies, eyelid lesions, and surgical procedures. Any breach in the skin barrier
at the eyelid can cause preseptal cellulitis.13 , 14 It is important to distinguish preseptal cellulitis

Please cite this article as: A.A. Gordon, D.J. Danek and P.O. Phelps, Common inflammatory and infectious conditions of
the eyelid, Disease-a-Month, https://doi.org/10.1016/j.disamonth.2020.101042
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Fig. 3. Right upper eyelid preseptal cellulitis. Note the erythema, edema, and mechanical ptosis related to swelling.
However, no orbital signs (chemosis, strabismus, proptosis, etc.) are seen. .

from orbital cellulitis, which has involvement of the globe and orbital structures. Fortunately,
preseptal cellulitis is far more common than orbital cellulitis.15
Exam: Patients will present with an erythematous and edematous eyelid. (Fig. 3) They may
report pain at the eyelid or discomfort. Because preseptal cellulitis does not involve the poste-
rior orbital structures, by definition, patients should not have signs of orbital involvement on
exam. Practitioners should conduct a very thorough eye exam, with particular attention paid to
visual acuity and extraocular movements. These patients should not have visual acuity changes
or motility dysfunction. In patients where foreign body or trauma is a concern, the practioner
should be careful to examine for an open globe injury.
Basic labs including a CBC are often drawn by physicians and may be significant for a leuko-
cytosis. Blood cultures are rarely positive14 and are not needed in routine care. Patients do not
require imaging unless orbital cellulitis is diagnosed or suspected, or there is other clinical indi-
cation such as foreign body or trauma.
Treatment: Most patients with preseptal cellulitis can be managed in the outpatient setting
with oral antibiotics. For adult patients and children older than one year, outpatient manage-
ment is appropriate. These patients should be treated with empiric antibiotic directed against
the most common agents causing respiratory infections and sinusitis. Staphylococcus and Strep-
tococcus species, in particular, are common culprits in the modern era, though Haemophilus in-
fluenza was once more common and remains a concern in unvaccinated populations.13 , 14 A com-
monly used antibiotic regimen is amoxicillin/clavulanic acid, maintained for 7–10 days.15 Im-
portant to remember is that concurrent sinusitis should also be treated with appropriate nasal
hygiene and decongestants.
Patients that require admission immediately for intravenous antibiotics include immunocom-
promised individuals, young children, or those with systemic infection.13 For any patient that
fails to respond to oral antibiotics, or is unable to maintain close follow up, a practioner should
admit for intravenous antibiotics. Additionally, young patients in particular should be monitored
for prolonged eyelid swelling, given there is some concern for amblyopia.16

Conclusion

Eyelid concerns are one of the most common presentations to an ophthalmologist office, and
many of these diseases can also be managed by a primary care physician. Dry eye, chalazion,
stye and preseptal cellulitis can usually be managed in the outpatient setting. For patients with
atypical lesions or severe presentations, referral to an ophthalmologist is always a good option.

Acknowledgments

We thank Mira Shiloach, MS, CCRP for her edits.

Please cite this article as: A.A. Gordon, D.J. Danek and P.O. Phelps, Common inflammatory and infectious conditions of
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Please cite this article as: A.A. Gordon, D.J. Danek and P.O. Phelps, Common inflammatory and infectious conditions of
the eyelid, Disease-a-Month, https://doi.org/10.1016/j.disamonth.2020.101042