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BASICS

Description

  • Acute inflammation/infection of eyelid margin.
  • External hordeolum: sebaceous gland of eyelash.
  • Internal hordeolum: meibomian gland, may cause pustule on conjunctival surface.
  • Synonyms: internal/external hordeolum, zeisian/meibomian stye.

Epidemiology

  • No age or sex predilection.
  • External hordeolum common; internal hordeolum rare.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Bacterial infection of sweat or sebaceous glands.
  • Most cases caused by Staphylococcus aureus (90-95%) or Staphylococcus epidermidis.
  • Seborrhea predisposes to eyelid infections.

Risk Factors

  • Poor eyelid hygiene
  • Previous hordeolum
  • Contact lens use
  • Makeup application
  • Seborrheic dermatitis
  • Predisposing blepharitis
  • Ocular rosacea

Prevention

  • Maintain eyelid hygiene.

DIAGNOSIS

History

  • Localized eyelid inflammation, foreign body sensation.
  • Symptoms start as vague pain, localizing after 1-2 days.
  • Prior episodes common.

Physical Exam

  • Localized eyelash inflammation or small pustule on eyelid margin.
  • Swelling and tenderness on internal or external eyelid.
  • For internal hordeolum, eyelid eversion reveals pustule on tarsal conjunctiva.
  • Itching, scaling, discharge, redness.

Differential Diagnosis

  • Chalazion
  • Blepharitis
  • Eyelid neoplasms
  • Periorbital cellulitis
  • Dacryocystitis
  • Squamous cell carcinoma

Diagnostic Tests

  • Culture generally unnecessary.
  • Diagnosis primarily clinical.

TREATMENT

General Measures

  • Do NOT express hordeolum.
  • Warm compresses to increase blood flow and encourage spontaneous drainage.
  • Daily cleansing of eyelids to prevent recurrence.

Medications

  • Topical antibiotic ointment (erythromycin, bacitracin) after cleansing—especially in children >12 years.
  • Limited evidence for efficacy of topical antibiotics.
  • Treat underlying dry eye with artificial tears.

Second Line

  • Ophthalmic aminoglycoside ointments (gentamicin, tobramycin) for refractory cases.
  • Oral dicloxacillin or cephalexin for 2 weeks if topical fails.

Referral

  • Consider ophthalmology referral if unresponsive to oral antibiotics.

SURGERY/OTHER PROCEDURES

  • Incision and drainage or curettage if localized abscess develops.
  • Procedure performed with local anesthesia in-office.
  • Caution: risk of ocular perforation during anesthetic injection.
  • Post-procedure antibiotic ointment has no proven added benefit.

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Broncasma Berna vaccine may help recurrent cases.
  • Acupuncture may improve outcomes but evidence is low quality.

ONGOING CARE

Follow-up

  • Reassess in several weeks or sooner if worsening.
  • No restrictions on activities.

Patient Education

  • Proper eyelid cleansing: diluted baby shampoo or hypoallergenic cleanser.
  • Avoid squeezing or incising the stye.
  • Maintain good eyelid hygiene to prevent recurrence.

PROGNOSIS

  • Typically resolves with hygiene and warm compresses within one week.
  • Recurrence possible due to incomplete bacterial eradication.

COMPLICATIONS

  • Untreated internal hordeolum may cause chalazion, adjacent gland infections, or lid cellulitis.

REFERENCES

  1. Lindsley K, Nichols JJ, Dickersin K. Non-surgical interventions for acute internal hordeolum. Cochrane Database Syst Rev. 2017;1(1):CD007742.
  2. Wald ER. Periorbital and orbital infections. Pediatr Rev. 2004;25(9):312-320.
  3. Mueller JB, McStay CM. Ocular infection and inflammation. Emerg Med Clin North Am. 2008;26(1):57-72, vi.
  4. Alsoudi AF, Ton L, Ashraf DC, et al. Efficacy of care and antibiotic use for chalazia and hordeola. Eye Contact Lens. 2022;48(4):162-168.
  5. Cheng K, Law A, Guo M, et al. Acupuncture for acute hordeolum. Cochrane Database Syst Rev. 2017;2(2):CD011075.

Clinical Pearls

  • Never express a hordeolum manually.
  • Warm compresses encourage spontaneous drainage.
  • Antibiotic ointment may reduce bacterial growth but does not hasten healing.
  • Daily eyelid hygiene is key to preventing recurrence.