Chalazia appear most commonly as chronic subcutaneous nodules within the eyelid. A chalazion results from the obstruction of the meibomian gland leading to blockage of the gland’s duct at the eyelid margin and then release of the contents of the gland into the surrounding eyelid soft tissue [10, 11]. A chalazion arises as a mild to moderately tender red swelling of the upper or lower eyelid (Fig. 5.2). At various locations and stages, multiple lesions may appear. Clinical onset of a chalazion occurs over days, with the redness and tenderness subsiding while the lump remains [10]. Patients usually present when the lump becomes symptomatic, either due to cosmetic reasons or if the chalazion is of a considerable size, because it is causing ptosis, astigmatism, and/ or vision loss [12].

Patients with underlying conditions such as rosacea, seborrheic dermatitis or blepharitis, and diabetes are more prone to multiple and recurrent chalazia.

If left untreated, chalazia may spontaneously resolve over many months. Management includes warm compresses application with topical corticosteroids and antibiotic, if signs of infection are present. If the lesion persists in spite of medical therapy, it may be incised and drained [11]. Steroid injections can be applied either intralesionally or subcutaneously and are considered to be a simple and effective treatment with reported success and resolution in 50–95 % of cases [12–17].

Anterior bacterial blepharitis affecting the base of the eyelashes is often caused by staphylococcal infection (Staphylococcus epidermidis, Staphylococcus aureus). Other causative organisms include Propionibacterium acnes, Corynebacteria, and Moraxella. Blepharitis predominantly involves young to middle-aged women and is associated with keratoconjunctivitis sicca in up to 50 % of patients [18]. There is a wide variety of ocular symptoms including sore eyelids, eyes feeling irritated, itchy, burning, or gritty, red eyes, dry or watery eyes, increased frequency of blinking, foreign body sensation, photophobia, contact lens intolerance, and eyelids sticking together, particularly in the morning [18]. Signs include swollen eyelids, inflamed lid margins with redness, thickening, and collarettes surrounding the eyelashes (Fig. 5.3), scaling, crusting, irregularity, and/or ulceration of the lid margins, altered eyelash appearance, individual lash poliosis, and lashes broken, misdirected, or crusted with fibrinous or sebaceous matter, as well as secondary alterations to the conjunctiva and cornea. Hordeolum and multiple and recurrent chalazia may occur in the course of bacterial blepharitis [18]. Staphylococcal blepharitis may be also associated to seborrheic blepharitis.

The clinical diagnosis of staphylococcal blepharitis may be confirmed by culture, which usually reveals many S. aureus organisms on the lid margins.

A combination of lid hygiene with warm compresses, lid scrubs, and antibiotherapy is required. Erythromycin or bacitracin ointments and fusidic acid gel have been the most frequently used agents for blepharitis. Aminoglycosides such as gentamycin or tobramycin eyedrops or ointment are also useful but do not have the same broad coverage against gram-positive bacteria [18]. Topical vancomycin 50 mg/mL four times daily has been used to treat resistant Staphylococcus [18]. Fluoroquinolones such as ciprofloxacin ophthalmic solution 0.3 % and topical levofloxacin 0.5 % proved their efficacy in the management of bacterial blepharitis [18–20]. The fourth-generation fluoroquinolones are also used for the treatment of bacterial blepharitis [21]. Corticosteroid-antibiotic combinations are also available in either ointment or eyedrop form [22, 23]. Most experts recommend corticosteroids for short-term use only (less than 2 weeks) in an effort to “jump start” therapy for moderate-to-severe anterior blepharitis or blepharoconjunctivitis. One of the more recent additions to the management of blepharitis is topical azithromycin [24, 25]. Prevention is based on careful cleaning of the eyelids which is the most effective way to prevent bacterial blepharitis and its recurrence.

Erysipelas is a bacterial skin infection most often caused by Group A Streptococcus. Patients typically develop symptoms including high fever, shaking, chills, fatigue, headaches, vomiting, and general illness within 48 h of the initial infection. Eyelid involvement appears as erythematous swollen, warm, hardened, and painful skin lesion with sharply demarcated raised edge that enlarges rapidly. More severe infections can result in vesicles, bullae, and petechiae, with possible skin necrosis [26, 27]. Lymph nodes may be swollen, and lymphedema may occur.

Penicillin administered orally or intramuscularly is sufficient for most cases of classic erysipelas and should be given for 10–20 days. A first-generation cephalosporin or macrolide, such as erythromycin or azithromycin, may be used if the patient has an allergy to penicillin [28].

Impetigo of the eyelid is caused by superinfection of skin disorder such as eczema, poison ivy, insect bites, and cuts or scrapes due to minor trauma by Staphylococcus aureus or Streptococcus pyogenes. The infection is more common in children younger than 6 years of age [29, 30]. Impetigo contagiosa of the eyelid is usually associated with infection of the face. Impetigo begins as tiny blisters, which eventually burst and leave small wet patches of red skin that may weep fluid. Gradually, a tan or yellowish-brown crust covers the affected area.

Cleansing of the affected area and local antibiotics ointments are generally effective. Systemic antibiotics are sometimes necessary.

The term preseptal cellulitis refers to an infectious process in the eyelids that is isolated to regions anterior to the orbital septum (Chap. 3).