Eyelid disorders: blepharitis, chalazion, ptosis, and skin cancer

Eyelid conditions in Australian general practice

The eyelid is one of the most functionally complex structures in the body — four cell layers deep, housing specialised glands at the margin, protecting the cornea during blink, and bearing the same UV risk as any other sun-exposed skin in Australia. Eyelid complaints are among the most common ophthalmological presentations to general practice.

eTG complete identifies blepharitis, hordeolum (stye), and chalazion as the dominant presentations. RANZCO adds ptosis and eyelid malignancy to the GP’s core skill set, particularly in the Australian context of high UV exposure and an ageing population.

Most eyelid conditions are diagnosable clinically, with the GP’s role being: accurate diagnosis, first-line treatment, recognition of red-flag features, timely biopsy of suspicious lesions, and referral to optometry or ophthalmology when needed.

A. Core clinical — the AU general-practice framework

Blepharitis

Blepharitis is chronic inflammation of the eyelid margin and the most common eyelid condition seen in general practice. It is a long-term condition that requires ongoing management rather than a single course of treatment.

Anterior blepharitis affects the lash follicles and anterior lid margin:

• Staphylococcal — hard scales (collarettes) around lash bases, eyelash loss (madarosis), recurrent styes, lid-margin ulceration
• Seborrhoeic — greasy scales, often associated with seborrhoeic dermatitis of the scalp, brows, and nasolabial folds

Posterior blepharitis (meibomian gland dysfunction, MGD) affects the oil-secreting meibomian glands in the tarsal plate behind the lashes. Signs include capped or telangiectatic meibomian orifices, foamy secretions, and lid-margin telangiectasia. MGD is strongly associated with rosacea and causes evaporative dry eye — gritty, burning sensation and fluctuating blur.

Demodex infestation of the lash follicles causes a distinctive cylindrical collarette pattern and should be considered in refractory blepharitis, particularly in older adults.

Management of blepharitis, per eTG:

1. Warm compresses for 5–10 minutes once or twice daily, followed by lid massage to express meibomian secretions
2. Lid hygiene with diluted baby shampoo or commercial lid wipes (OcuSoft, Sterilid, Blephadex) along the lid margin
3. Preservative-free artificial tears for associated dry-eye symptoms
4. Topical chloramphenicol 0.5% drops or 1% ointment for staphylococcal blepharitis flares (PBS-listed)
5. Oral doxycycline 50–100 mg daily for 6–12 weeks for refractory MGD or ocular rosacea (off-label PBS; anti-inflammatory effect on gland secretions)
6. Tea-tree-oil lid scrubs (5%) for Demodex — pharmacy-available; randomised trial evidence supports reduction in mite counts and symptom improvement

Counsel patients that blepharitis is a chronic condition requiring ongoing lid hygiene. Avoid eyeliner and mascara applied to the lid margin. Replace eye cosmetics regularly.

Stye and chalazion

A stye (external hordeolum) is an acute Staphylococcus aureus infection of a lash follicle or accessory gland. It presents as a tender, red lid-margin lump and typically resolves within 1–2 weeks with warm compresses alone. Antibiotics are not needed for uncomplicated stye — antimicrobial stewardship applies. Topical chloramphenicol ointment is appropriate only if surrounding preseptal cellulitis develops.

A chalazion is a sterile granulomatous reaction to a blocked meibomian gland. It presents as a painless, firm, rubbery lump within the tarsal plate — typically painless (unlike a stye). First-line: warm compresses four times daily. Around 30–50% resolve within 4–6 weeks.

For persistent chalazion beyond 4–6 weeks, refer for:

• Intralesional triamcinolone (approximately 70% resolution rate; preferred in darker skin to avoid hypopigmentation from incision)
• Incision and curettage via conjunctival approach (avoids skin scar; performed by ophthalmologist or GP with procedural training)

Red flag: Any recurrent, atypical, or unilateral chalazion in an older adult — particularly if the overlying skin is indurated or lashes are disrupted — requires biopsy to exclude sebaceous carcinoma (a rare but high-mortality malignancy that masquerades as chalazion).

Ptosis

Ptosis is drooping of the upper eyelid. The clinical priority is identifying neurological causes before assuming involutional aetiology.

Aponeurotic / involutional ptosis (most common in adults) — gradual-onset from levator muscle disinsertion; associated with age or prior contact-lens wear; typically bilateral; high lid crease. Safe for elective ophthalmology referral.

Neurological causes — examine the pupil first:

Sign	Diagnosis	Urgency
Ptosis + large ipsilateral pupil + eye deviated “down and out”	Third-nerve palsy → posterior communicating artery aneurysm	Neurosurgical emergency — urgent CT/CTA
Ptosis + small ipsilateral pupil + anhidrosis	Horner syndrome → carotid dissection, Pancoast tumour	Urgent — same-day imaging
Variable, fatigable ptosis + diplopia	Myasthenia gravis	Semi-urgent — acetylcholine receptor antibodies, CT thymus

Any sudden ptosis, or ptosis associated with pupil asymmetry, diplopia, headache, or neck pain, requires urgent assessment.

B. Eyelid skin cancer — the Australian context

Australia has the world’s highest incidence of skin cancer, and the eyelid is a UV-exposed site with specific implications: its proximity to the cornea and lacrimal apparatus means incomplete excision can result in corneal exposure and epiphora, and reconstruction after excision requires specialist technique.

Basal cell carcinoma (BCC) accounts for approximately 90% of eyelid skin cancers and most commonly affects the lower lid. Presentations:

• Pearly, nodular lesion with telangiectasia
• Central ulceration (“rodent ulcer”)
• Morphoeic (flat, scar-like) variant — easily missed
• Slow-growing; locally destructive; rarely metastasises

Squamous cell carcinoma (SCC) — keratotic, ulcerated, faster-growing; may involve preauricular or submandibular lymph nodes; higher-risk in immunosuppressed patients.

Sebaceous carcinoma — rare but aggressive; arises from meibomian or Zeis glands; upper lid predominant; frequently misdiagnosed as recurrent chalazion or chronic blepharitis for months before recognition. Pagetoid conjunctival spread occurs. Any unilateral recurrent chalazion in an older adult without obvious precipitant: biopsy is mandatory.

Melanoma — pigmented, irregular, asymmetric, evolving lesion; refer urgently to oculoplastic surgery.

Red flags requiring biopsy or oculoplastic referral:

• Persistent (over 3–4 weeks) ulcerated, bleeding, or non-healing lesion
• Lash loss (madarosis) at the site
• Disruption of lid architecture
• Pigmented lesion with ABCDE features
• Recurrent chalazion in adults over 50

Avoid full excision of lid-margin lesions in general practice — proximity to lacrimal puncta and the cornea means partial excision or distorted margins create difficult reconstructive problems. Incisional or punch biopsy to confirm histology first; definitive resection by oculoplastic surgeon or Mohs surgery.

Cancer Council Australia recommends annual skin cancer surveillance in high-risk individuals, including eyelid inspection.

C. Other eyelid conditions

Entropion (lid turns inward — lashes contact cornea) and ectropion (lid turns outward — corneal exposure, epiphora) are predominantly involutional in older Australians. Both cause corneal damage if untreated. Lubrication bridges to surgical correction, which is definitive. Refer to ophthalmology.

Herpes zoster ophthalmicus (HZO) — V1-distribution vesicular rash involving the eyelid. Hutchinson sign (vesicles on the tip of the nose) indicates nasociliary nerve involvement and high risk of corneal disease. Start oral antiviral within 72 hours of rash onset (valaciclovir per eTG) and refer urgently to ophthalmology.

Eyelid contact dermatitis — often allergic to cosmetics, nail polish (transferred via finger-to-eye contact), or preservatives in eye drops. Patch testing by dermatology identifies the trigger.

Floppy eyelid syndrome — upper lids that evert easily; associated with obstructive sleep apnoea and obesity; presents with chronic papillary conjunctivitis. Screen for OSA.

Xanthelasma — yellowish lipid plaques near the medial canthus. Check a fasting lipid profile; treat underlying dyslipidaemia.

D. Australian operations

MBS items

Standard GP consultations (items 23 / 36 / 44) cover assessment, counselling, and management of blepharitis, stye, and chalazion. Item 44 is appropriate for a comprehensive ptosis workup or suspected eyelid malignancy consultation.

Procedural items: biopsy of skin lesion (item 30071); incision and drainage (30219). Eyelid-specific surgical items (chalazion curettage 45620; eyelid biopsy/lesion excision 45617) are typically performed by ophthalmologists or oculoplastic surgeons.

ATSI health assessment (item 715) is an opportunity to screen for trachoma in patients from remote communities and for diabetes-related eyelid healing risk.

PBS

Chloramphenicol 0.5% eye drops / 1% ointment — PBS general listing. Fusidic acid 1% viscous eye drops — PBS general listing. Oral doxycycline 50/100 mg — PBS general listing under acne indication (off-label for blepharitis). Valaciclovir / aciclovir — PBS-listed for herpes zoster. Imiquimod 5% / fluorouracil 5% — PBS-listed for select superficial BCC under criteria.

Referral pathways

• Optometry — therapeutic-endorsed optometrists (TPA) can prescribe ocular medications and co-manage blepharitis; first-line for most chronic lid and dry-eye presentations
• Ophthalmology — refractory blepharitis, chalazion over 6 weeks, suspected sebaceous carcinoma, ptosis with neurological signs, corneal involvement
• Oculoplastic surgeon — eyelid neoplasm excision and reconstruction, ptosis surgery, entropion/ectropion repair
• Dermatology — atypical pigmented lesion, biologic therapy for rosacea-atopic overlap
• Neurology / neurosurgery — pupil-involving third-nerve palsy (urgent), Horner syndrome

Aboriginal and Torres Strait Islander considerations

Trachoma remains present in some remote Australian communities. The national SAFE strategy (Surgery, Antibiotics, Facial cleanliness, Environmental improvement) guides community-level response. Trichiasis from trachoma causes corneal scarring and preventable blindness — refer for surgery. MBS item 715 health assessments should include eyelid and trachoma screening in eligible patients.

E. Special populations

Children. Congenital ptosis requires paediatric ophthalmology review promptly — the ptotic lid can cause deprivation amblyopia (“lazy eye”) that is permanent if untreated in the critical developmental window. Childhood blepharitis is less common than in adults but does occur, particularly in children with atopic dermatitis.

Older adults. The dominant group for involutional entropion, ectropion, and aponeurotic ptosis, and for eyelid skin cancer. An annual skin examination should include the eyelid margins, particularly the lower lid and medial canthus. Demodex infestation prevalence increases significantly with age.

Immunosuppressed patients (transplant, biologic therapy, HIV). Higher risk for aggressive SCC and for HZO. Lower threshold for urgent ophthalmology referral with any unusual eyelid lesion.

Patients on long-term topical corticosteroid eye preparations. Risk of posterior subcapsular cataract and open-angle glaucoma with prolonged use. If topical steroids for blepharitis-associated inflammation are prescribed, ensure intraocular pressure monitoring.

When to escalate

Refer urgently (same-day or emergency) for:

• Sudden ptosis with pupil asymmetry, diplopia, headache, or neck pain — possible third-nerve palsy or carotid dissection
• Signs of orbital cellulitis (proptosis, pain on eye movement, reduced eye movements, fever) — IV antibiotics and specialist involvement required; differentiate from preseptal cellulitis
• Herpes zoster ophthalmicus with corneal signs or reduced vision

Refer semi-urgently (within 1–2 weeks) for:

• Suspected eyelid malignancy — any non-healing, lash-disrupting, or recurrent lid lesion
• Horner syndrome — carotid and chest imaging
• Chalazion unresolved at 6 weeks

What this article is and is not

This article is educational material prepared by an Australian GP to support patient understanding of common eyelid conditions. It draws on RANZCO, eTG, Cancer Council Australia, and RACGP guidance.

It is not a substitute for a personal clinical assessment. Eyelid conditions range from trivially self-limiting (most styes) to immediately life-threatening (posterior communicating aneurysm presenting as third-nerve palsy). If you have a new or changing eyelid problem, see your GP.

---

Sources cited

• RANZCO
• eTG complete — Eye, Antibiotic, Dermatology
• RACGP
• Cancer Council Australia — Skin cancer
• Australasian College of Dermatologists
• TFOS DEWS II — MGD guidelines
• Optometry Australia
• PBS — Chloramphenicol, doxycycline, antivirals
• HealthDirect — Eyelid problems
• Better Health Channel