Changes

October 2024 — minor update. The sections on diagnosis and management have been updated. No major changes to the recommendations have been made.

April 2024 — reviewed. A literature search was conducted in March 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to the recommendations have been made.

Update

Goals

To support primary healthcare professionals to:

• Assess a person with a suspected meibomian cyst.
• Make a diagnosis of meibomian cyst.
• Advise on appropriate self-care measures to facilitate resolution and prevent recurrence.
• Identify and refer people who need specialist management.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE Quality standards

No NICE quality standards were found during the review of this topic.

What is it?

• A meibomian cyst (or chalazion) is a chronic, non-infectious, inflammatory granuloma caused by blockage of meibomian gland duct(s).
  • The meibomian glands (located in the tarsal plate) are a set of glands that run along the eyelid margin. They produce a lipid secretion that provides the lipid layer of the tear film.
  • Obstruction of the gland duct causes the gland to enlarge and rupture, releasing the accumulated lipid contents into the surrounding eyelid soft tissue.
  • This triggers an inflammatory reaction against the lipid content (a lipogranulomatous reaction), which subsides with time. Consequently, meibomian cysts are often painless and non-tender.
• A meibomian cyst may occur spontaneously or follow an acute internal stye. 
  • The swelling may drain spontaneously or persist as a chronic nodule.

[BMJ, 2023; College of Optometrists, 2023; Jordan, 2023]

Prevalence

• Meibomian cysts are the most common inflammatory lesions of the eyelids.
  
  • They can occur at any age but are thought to be more common in adults (ages 30–50).
  • There are no known differences in prevalence between sexes or races.

 [Sun, 2019; Sahu, 2021]  [BMJ, 2023; Jordan, 2023]

What are the risk factors?

• Risk factors for meibomian cysts include:
  • Acute stye. For more information, see the CKS topic on Styes (hordeola).
  • Chronic blepharitis. For more information, see the CKS topic on Blepharitis.
  • Seborrhoeic dermatitis. For more information, see the CKS topic on Seborrhoeic dermatitis.
  • Rosacea. For more information, see the CKS topic on Rosacea - acne.
  • Diabetes mellitus. For more information, see the CKS topics on Diabetes - type 1 and Diabetes - type 2.
  • Elevated serum cholesterol.
  • Pregnancy.

[BMJ, 2023; College of Optometrists, 2023] 

What is the prognosis?

• Most meibomian cysts resolve spontaneously or with conservative treatment, although it may take weeks or months.
• If conservative treatment fails, invasive treatments, such as incision and curettage or intralesional injection of steroid, can be performed.
• Recurrence is more common in people with ongoing risk factors, such as chronic blepharitis.

[BMJ, 2023; College of Optometrists, 2023; Jordan, 2023]

What are the complications?

• Complications of meibomian cysts include:
  
  • Visual disturbances — large meibomian cysts can cause visual disturbances (from mechanical ptosis or direct contact with the cornea), induce astigmatism (by pressing on the cornea), or affect eyelid closure. Large or multiple lesions involving the whole upper eyelid carry the greatest risk of inducing a change in corneal topography. Untreated astigmatism may result in loss of visual acuity and amblyopia.
  • Skin changes — persistent meibomian cysts may result in chronic skin changes overlying the inflammatory reaction.
  • Cellulitis — rarely, a meibomian cyst may become secondarily infected. This may develop into:  
    
    • Periorbital cellulitis — infection of tissues lying in front of the orbital septum (therefore, not an orbital condition). It typically presents with an acute onset of swelling, redness, and tenderness of the lids. However, it does not cause visual impairment, limited or painful eye movements, oedema of the conjunctiva, or eyeball protrusion. There may be associated fever and malaise.
    • Orbital cellulitis (rare) — infection of tissues lying behind the orbital septum (within the orbit). It presents with an acute onset of unilateral eyelid swelling, with a red and painful eye. It is often associated with severe pain, blurred or double vision, limited and painful eye movements, eyeball protrusion, headache, fever, and malaise. It is a medical emergency that can progress rapidly, potentially causing vision loss and serious complications, such as meningitis or a cerebral abscess.

[BMJ, 2023; College of Optometrists, 2023; Jordan, 2023; College of Optometrists, 2024]

How should I diagnose a meibomian cyst?

The diagnosis of a meibomian cyst is usually based on history and clinical examination. 

• Take a history.  
  • Ask about the lesion, including the character, speed of onset, progression, and duration.
    • A meibomian cyst typically presents as a firm lump in the upper (more common) or lower eyelid that has developed slowly over several weeks.
    • The lesion may be a little tender initially (as the inflammatory reaction occurs), but this settles rapidly. Consequently, meibomian cysts are often painless and non-tender.
    • Occasionally, two or more lesions may occur in a single lid. One or both eyes may be affected.
    • The lesion may occur spontaneously or follow an acute internal stye.
  • Ask about any associated symptoms. 
    • Large lesions may cause ptosis, astigmatism, and/ or vision loss or affect eye closure.
    • Symptoms such as pain, redness, burning, itching, limited or painful eye movements, fever, and malaise may suggest a risk factor (such as blepharitis or seborrhoeic dermatitis), a complication (such as cellulitis) or a differential diagnosis (such as a stye).
  • Ask about:
    • Medical history, including conditions that may increase the risk of meibomian cysts (such as diabetes and elevated serum cholesterol).
    • Known triggers, such as contact lens use or applying cosmetics, fragrances, or haircare products.
    • Previous episodes of meibomian cyst(s). 
• Examine the person. 
  
  • Look for signs of meibomian cysts.
    • On examination of the eyelid, a well-defined, 2–8 mm diameter subcutaneous nodule is noted in the tarsal plate, most commonly sited away from the lid margin.
    • Two or more lesions may occur in a single lid; multiple lesions may look like diffuse swelling of the lid.
    • The overlying skin is usually normal but may occasionally be indurated. Ptosis may be evident.
    • Lid eversion may show external conjunctival granuloma. Erythema is usually absent.
    • There may be signs of minor conjunctival infection secondary to mechanical irritation or manipulation of the eye by the person.
  • Assess for:
    • Risk factors for meibomian cysts (such as blepharitis and seborrhoeic dermatitis).
    • Differential diagnoses of meibomian cysts (such as styes and sebaceous cysts). Note that in the initial (acute) phase, a meibomian cyst may be difficult to differentiate from an internal stye. 
  • Be alert for signs and symptoms of a serious underlying condition, including:
    • A firm, warm, tender, erythematous, oedematous eyelid associated with severe pain, blurred/double vision, limited and painful eye movements, headache, fever, and malaise — suggestive of associated orbital cellulitis. 
    • Atypical clinical features (such as distortion of the eyelid margin, eyelash loss, ulceration, or bleeding) — suggestive of possible eyelid cancer.  
    • Chronic or recurrent lesions in the same location (especially in older people) — suggestive of possible sebaceous gland carcinoma.
•  Investigations are not routinely required but may be needed to exclude a risk factor, complication, or differential diagnosis.

What are the differential diagnoses?

• The differential diagnoses of a meibomian cyst include:
  • Stye (hordeola) — suggested by an acutely painful pustule located either at the eyelid margin (an external stye, caused by infection of an eyelash follicle) or in the tarsal plate (an internal stye, caused by infection of a meibomian gland). For more information, see the CKS topic on Styes (hordeola). 
  • Dacryocystitis — inflammation or infection of the lacrimal sac, often caused by blockage of the nasolacrimal duct. Symptoms include pain and swelling in the inner corner of the eye, redness, purulent discharge, and excessive tearing. 
  • Dacryoadenitis — inflammation or infection of the lacrimal (tear) gland. Symptoms include pain and swelling in the upper outer eyelid, redness, and possible tearing and discharge from the eye. The condition can be acute or chronic and may result from infection, autoimmune disease, or other underlying health conditions.
  • Sebaceous cysts — may result from inflammation around a pilosebaceous follicle or from deep implantation of the epidermis by a blunt, penetrating injury. Young and middle-aged adults are most frequently affected; they are rare in childhood. Lesions are commonly on the face, neck, shoulders, and chest, are often multiple, and tend to be asymptomatic unless they become infected. 
  • Malignant eyelid tumours — basal cell carcinoma, squamous cell carcinoma, and melanoma are the most frequently encountered malignant tumours involving the eyelids. Sebaceous gland carcinoma is a rare and aggressive tumour most commonly found on the eyelids but can develop in any sebaceous gland.
    • Eyelid cancer should be suspected in people with atypical, unilateral, inflammatory eyelid disease that is unresponsive to treatment.
    • Features such as eyelid distortion, nodular mass, ulceration, bleeding, extensive scarring, lash loss, localized crusting and scaling of the dermis, or yellow conjunctival nodules surrounded by intense inflammation may suggest the presence of eyelid cancer. For information on the recognition and referral of suspected skin cancers, see the CKS topic on Skin cancers - recognition and referral.
    • Sebaceous cell carcinoma should be considered in people with chronic or recurrent lesions in the same location, particularly older people.

Scenario: Management of meibomian cyst

From age 1 month onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of meibomian cyst.

Search dates

March 2019 - March 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 13th March 2019). All results from the search were screened.  The strategy was adapted for The Cochrane Library databases. 

S4    S1 OR S2 OR S3 
S3    AB meibomian N2 cyst* OR TI meibomian N2 cyst* 
S2    AB chalazi* OR TI chalazi* 
S1    (MH "Chalazion") 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.