Purpose
To detect risk factors that may be related to chalazia in children in southwest China.
Design
Prospective case-control study.
Methods
The case group, 88 children with chalazia, was divided into 2 subgroups. One had 48 children 6 months to 6 years of age (defined as young children), and the other had 40 children 7 to 12 years of age (defined as older children). The control group consisted of 40 young children and 32 older children. Clinical findings for patients were recorded. Serum was tested for concentrations of vitamin A, vitamin D3, and immunoglobulin E.
Results
World Health Organization definitions were used for vitamin A deficiency (< 0.7 μmol/L) and marginal vitamin A deficiency (0.7 to 1.05 μmol/L). The average level of serum vitamin A in the case group was significantly lower than that in the control group ( P < .001). Analyses failed to find significant differences in vitamin D3 or immunoglobulin E levels between the case and control groups. The average vitamin A level in young children with multiple chalazia (0.65 ± 0.12 μmol/L) was low. Blepharitis was less prevalent than low serum vitamin A levels in the young child subgroup (odds ratios, 8.5 and 96.9, respectively), but higher than in older children (odds ratios, 17.5 and 9.0, respectively).
Conclusions
Low serum vitamin A is associated with a chalazion in young children in southwest China, especially young children with multiple chalazia.
A chalazion is a localized, lipogranulomatous inflammation and is one of the most common eye diseases affecting the sebaceous glands, particularly the meibomian glands of the eyelids. Chalazia often occur secondary to noninfectious blockage of the sebaceous gland ducts. Previous studies have revealed that several risk factors, including blepharitis, infection of a virus or Demodex brevis, rosacea, gastritis, anxiety, irritable bowel syndrome, and smoking, are associated with chalazia. Hyperimmunoglobulin E syndrome and pulmonary tuberculosis also are reported risk factors. However, most studies have focused on risk factors leading to chalazia in adults and teenagers, and little attention has been paid to the factors that may relate to chalazia in children, especially young children.
In our clinical work, we found that chalazia in young children had different clinical manifestations than chalazia in adults and teenagers. In younger children, chalazia usually featured multiple lesions, increased susceptibility to infection, and higher recurrence than chalazia in older children. In some young children with multiple chalazia, the total number can reach more than 10 lesions in both eyelids. Most children with multiple chalazia also have frequent recurrences. In addition to conservative therapies, such as eyelid hygiene, local hot compresses, topical antibiotic agents, and eyelid massage, surgical methods often are used, including subcutaneous steroid injections and lesion excision. The pain caused by surgical methods and by the disease and the frequent recurrence in young children prompted this examination of other factors that may be involved in the morbidity of chalazia in children.
Vitamin A is a fat-soluble vitamin that plays an important role in reproduction, the visual cycle, and the differentiation and maintenance of epithelial tissues. Evidence is mounting that vitamin A deficiency can lead to metaplasia of the glandular, ciliated, mucus-secreting epithelium and hyperkeratosis of the keratinizing epithelium. Vitamin D is a very important nutrient that influences children’s growth and development. Deficiencies in the final, active metabolite of vitamin D (1,25(0H) 2 D3) have been reported to result in a set of diseases in children, including rickets and type 1 diabetes. These findings prompted investigation of whether levels of vitamin A, vitamin D3, and immunoglobulin E (IgE) are associated with chalazia in children.
Methods
Study Population
This was a prospective case-control study of 88 children with chalazia. The Ethics Committee of the Children’s Hospital of Chongqing Medical University, Chongqing, China, approved the study (permit no., 001/2013). The tenets of the Declaration of Helsinki were followed in all procedures. Written informed consent was obtained from the parents of the participants before blood was drawn. This study was registered in the Chinese Clinical Trial Registry. The registration number is ChiCTR-OCC-14004140.
Patients were enrolled at Children’s Hospital of Chongqing Medical University, Chongqing, China, from June through November 2013. The phenomenon that clinical characteristics of chalazia in young children were different from those of chalazia in older children was discovered in clinical practice. Therefore, to minimize bias, the case group was divided into 2 subgroups by age: a group of 48 children 6 months to 6 years of age (defined as young children) and a group of 40 children 7 to 12 years of age (defined as older children). Chalazia was identified by the patients’ medical histories of presenting with gradually enlarging eyelid nodules manifesting pain, inflammation, and tenderness in the acute phase and a persistent, nontender mass in the chronic phase. Blepharitis, diagnosed with the standard lid examination technique and quantified by changes in the lid condition, was defined as an inflammation in the palpebral margin involving the skin, lashes, and meibomian glands. Table 1 shows clinical findings for the children with chalazia, including age, gender, and symptoms. During the same period, an age- and gender-matched control group was recruited from Children’s Hospital of Chongqing Medical University. The control group consisted of 40 young children and 32 older children. Individuals in the control group had undergone surgery for strabismus, congenital ptosis, congenital cataract, or ocular trauma. Blood from the individuals in the control group was drawn before surgery. Because infants 0 to 6 months of age have lower serum vitamin A levels than older children, children younger than 6 months were excluded from the study.
| Case Group (n = 88), No. (%) | Control Group (n = 72), No. (%) | P Value | |
|---|---|---|---|
| Male-to-female gender | 47:41 | 37:35 | |
| Age (mean ± SD), y | 5.24 ± 3.64 | 5.17 ± 3.65 | |
| Patients with a chalazion, no. (%) | 48 (54.5) | ||
| Patients with 2 or more chalazia, no. (%) | 40 (45.5) | ||
| Relapsing patients, no. (%) | 31 (35.2) | ||
| Patients with infected chalazia, no. (%) | 45 (51.1) | ||
| Patients with blepharitis, no. (%) | 42 (47.7%) | ||
| Vitamin A level, mean ± SD (μmol/L) | 0.84 ± 0.24 | 1.08 ± 0.31 | <.001 |
| Vitamin A level in patients with multiple chalazia, mean ± SD (μmol/L) | 0.70 ± 0.15 | 1.08 ± 0.31 | <.001 |
| Vitamin D3 level, mean ± SD (nmol/L) | 44.48 ± 6.75 | 43.26 ± 4.91 | .298 |
| Vitamin D3 level in patients with multiple chalazia, mean ± SD (nmol/L) | 44.75 ± 6.65 | 43.26 ± 4.91 | .257 |
| IgE level, mean ± SD (IU/mL) | 11.25 ± 17.62 | 8.81 ± 7.94 | .558 |
| IgE level in patients with multiple chalazia, mean ± SD (IU/mL) | 10.88 ± 16.51 | 8.81 ± 7.94 | .502 |
Clinical Laboratory Analyses
The blood samples were collected at similar months of the year for the case and control groups. Serum was tested for levels of vitamin A, vitamin D3, and IgE in the clinical laboratory of the Children’s Hospital of Chongqing Medical University using a high-performance liquid chromatograph (Shimadzu, Kyoto, Japan) and a chemiluminescence immune assay system (ADVIA Centaur, Pittsburgh, Pennsylvania, USA). World Health Organization definitions were used for vitamin A deficiency (< 0.7 μmol/L) and marginal vitamin A deficiency (0.7 to 1.05 μmol/L). Vitamin D3 deficiency and hyperimmunoglobulin E were considered to be present if concentrations were less than 17.25 nmol/L and more than 150 IU/mL, respectively.
Statistical Analysis
Data on the serum levels of vitamin A, vitamin D3, and IgE are shown as mean ± standard deviation. One-way analyses of variance, independent-samples tests, and Nemenyi tests were performed to analyze levels of serum vitamin A, vitamin D3, and IgE using SPSS software version 13.0 (SPSS, Inc, Chicago, Illinois, USA). Logistic regression analysis was applied to adjust for simultaneous effects of low serum vitamin A levels and blepharitis in children with chalazia. An χ 2 test was used to compare patients with a chalazion or multiple chalazia lesions, relapsing patients, patients with infected chalazia, and blepharitis in various groups. P values less than .05 were considered statistically significant.
Results
Clinical Findings for Children with Chalazia
Table 1 summarizes the vitamin A, vitamin D3, and IgE levels and clinical characteristics of the study subjects as assessed at diagnosis. In the case group, the average vitamin A level, in all patients (0.84 ± 0.24 μmol/L) and patients with multiple chalazia (0.70 ± 0.15 μmol/L) were marginally deficient. The average vitamin A level in all patients with chalazia or patients with multiple chalazia in the case group were significantly lower than those in the control group ( P < .001 and P < .001, respectively). Analyses failed to find significant differences in the average levels of vitamin D3 and IgE in the case and control groups.
Clinical Findings for Patients in Both Subgroups
Table 2 summarizes the vitamin A, vitamin D3, and IgE levels and clinical characteristics of both case subgroups. The distribution of patients with a chalazion or multiple chalazia, the number of relapsing patients (defined as patients who demonstrated a new chalazion near the location of a chalazion within 3 months after recovery from the excision and curettage for the chalazion), and the number of patients with infected chalazia were significantly different in the young child subgroup and the older child subgroup ( P < .001, P < .001, and P = .02, respectively). The rates of all 3 phenomena in the young child subgroup (62.5%, 52.5%, and 62.5%, respectively) were markedly higher than in the older child subgroup (25%, 15%, and 37.5%, respectively). The average vitamin A levels in the young child subgroup (0.77 ± 0.25 μmol/L) were marginally low and were low for young children with multiple chalazia (0.65 ± 0.12 μmol/L). Meanwhile, the average vitamin A level of the patients in the older child subgroup and older children with multiple chalazia (0.94 ± 0.20 μmol/L and 0.84 ± 0.15 μmol/L, respectively) were marginally low. The average vitamin A levels in patients in the young child subgroup or patients with multiple chalazia in the young child subgroup were significant lower than those in the older child subgroup ( P < .001 and P = .002, respectively). We did not find a significant difference in the average levels of vitamin D3 or IgE in these subgroups.
| Young Children (n = 48) | Older Children (n = 40) | P Value | |
|---|---|---|---|
| Male-to-female gender | 26:22 | 21:19 | |
| Age (mean ± SD), y | 2.13 ± 0.84 | 8.98 ± 1.56 | |
| Patients with a chalazion, no. (%) | 18 (37.5) | 30 (75) | <.001 |
| Patients with 2 or more chalazia, no. (%) | 30 (62.5) | 10 (25) | <.001 |
| Relapsing patients, no. (%) a | 25 (52.1) | 6 (15) | <.001 |
| Patients with infected chalazia, no. (%) | 30 (62.5) | 15 (37.5) | .02 |
| Patients with blepharitis, no. (%) | 19 (39.6) | 23 (57.5) | .09 |
| Vitamin A level (mean ± SD), μmol/L | 0.77 ± 0.25 | 0.94 ± 0.20 | <.001 |
| Vitamin A level in patients with multiple chalazia (mean ± SD), μmol/L | 0.65 ± 0.12 | 0.84 ± 0.15 | .002 |
| Vitamin D3 level (mean ± SD), nmol/L | 45.16 ± 7.10 | 43.67 ± 6.29 | .299 |
| Vitamin D3 level in patients with multiple chalazia (mean ± SD), nmol/L | 45.69 ± 7.11 | 41.90 ± 4.10 | .131 |
| IgE level (mean ± SD), IU/mL | 13.44 ± 22.68 | 8.62 ± 7.73 | .486 |
| IgE level in patients with multiple chalazia (mean ± SD), IU/mL | 12.14 ± 6.98 | 8.31 ± 2.34 | .416 |
a Patients with new chalazia near the location of a chalazion within 3 months after recovery from the excision and curettage for the chalazion.
Comparison of Vitamin A Levels in Case Subgroups and Control Subgroups
The results indicate that the average vitamin A levels in the case group were significantly lower than in the control group. To minimize bias, we compared the average vitamin A levels only between the young child case and control subgroups and the older child case and control subgroups, respectively ( Table 3 ). The average vitamin A levels in the young child case subgroup (0.77 ± 0.25 μmol/L) were markedly lower than in the young child control subgroup (1.08 ± 0.32 μmol/L; P < .001). Similarly, the average vitamin A levels in the older child case subgroup (0.94 ± 0.20 μmol/L) were lower than in the older child control subgroup (1.09 ± 0.30 μmol/L; P = .01).
