When should I consider referring a patient with a chalazion for surgical intervention?

You should consider referring a patient with a chalazion for surgical intervention in several circumstances:

• Suspected Malignancy: Refer for an assessment using a suspected cancer pathway if a malignant eyelid tumour is suspected ¹,². A lid biopsy may be warranted to exclude malignancies such as basal cell, squamous cell, or sebaceous cell carcinoma if there are atypical signs and symptoms ¹,². Features prompting further investigation include gradual enlargement, central ulceration or induration, irregular borders, eyelid margin destruction or loss of lashes, and telangiectasia ¹,². Persistent or recurrent meibomian cysts, especially in older people, should raise the possibility of sebaceous cell carcinoma ¹,². Lesions that recur in a particular location also require investigation to rule out cancer ¹,².
• Failure of Conservative Treatment: If a chalazion does not improve or resolve with conservative measures, referral to ophthalmology may be considered ¹,². While expert opinion suggests referral if symptoms persist beyond 4 weeks, the College of Optometrists advises that most chalazions resolve within 6 months with conservative management ¹,². If conservative treatment fails after 6 months, options such as incision and curettage or intralesional steroid injection may be considered for large or symptomatic lesions ¹,². For large and/or symptomatic lesions that do not improve or resolve after 4 weeks, CKS recommends considering referral to an ophthalmologist, depending on clinical judgement and patient preference ¹,².
• Impact on Vision in Young Children: Consider an ophthalmology referral for young children, particularly those with large (3 mm or more) or multiple meibomian cysts, astigmatism, or mechanical ptosis ¹,². Large lesions, those in the middle-upper eyelid, and multiple lesions can lead to secondary ptosis and aggravated astigmatism, potentially increasing the risk of amblyopia ¹,².
• Emergency Referral for Cellulitis: Although not a direct indication for chalazion surgery, it is critical to differentiate from periorbital or orbital cellulitis, which requires emergency hospital admission ¹,². Orbital cellulitis is a severe sight and life-threatening emergency ¹,². Emergency (same-day) referral to an ophthalmologist or emergency department is recommended for all adults and children with suspected orbital cellulitis, all children with suspected periorbital cellulitis, and adults with suspected periorbital cellulitis whose symptoms worsen or do not improve within 24–48 hours of primary care management ¹,².