Hordeolum (Stye)

Definition & Classification

Clinical Features

Hordeolum of the upper lid (Pfenninger & Fowler's Procedures for Primary Care)

Lower lid external hordeolum — note the pointing pustule at the lid margin (Goldman-Cecil Medicine)

• Acute, tender, erythematous, fluctuant mass at or near the lid margin
• Associated eyelid cellulitis (localized erythema, edema, warmth of surrounding skin) is common
• Spontaneous drainage typically occurs at 5–7 days, often with symptom resolution
• Multiple lesions may be present; entire lid margin may be involved in severe cases

Hordeolum vs. Chalazion

Key alert: A mass located nasal to the medial canthus suggests dacryocystitis, not hordeolum — refer urgently to ophthalmology (risk of dissection to cavernous sinus).

Differential Diagnosis

• Preseptal (periorbital) cellulitis — diffuse eyelid and periorbital erythema/edema
• Chalazion — chronic, non-infectious, lipogranuloma
• Dacryocystitis — medial canthal swelling, nasal to medial canthus
• Sebaceous carcinoma — suspect in older patients with recurrent/atypical lesions, madarosis, or chronic unilateral blepharitis
• Pyogenic granuloma — benign, deep-red pedunculated lesion often post-hordeolum or post-trauma

Workup

1. History: previous eyelid lesions, surgery, trauma, acne rosacea
2. External exam: palpate lid for nodule, assess for surrounding cellulitis
3. Slit-lamp exam: evaluate meibomian gland orifices, check for madarosis/poliosis (would suggest malignancy)

Treatment

Conservative (first-line)

• Warm compresses ≥10 minutes, 4× daily with gentle massage — promotes spontaneous drainage
• Topical antibiotics: bacitracin, tobramycin, or erythromycin ointment b.i.d. for 1–2 weeks
• Oral antibiotics directed against Staphylococcus (e.g., dicloxacillin, doxycycline) if significant cellulitis is present or lesion fails to point
• Most hordeola resolve with this regimen within 5–7 days

Incision & Drainage (I&D)

• Fails conservative management
• Significant pain
• Significant localized pus accumulation
• Associated or previous eyelid cellulitis

1. Topical ophthalmic anesthetic drops (e.g., tetracaine) + local infiltration with 2% lidocaine with epinephrine (30-gauge, 3-mL syringe)
2. Incise from whichever surface (anterior skin or posterior conjunctiva) provides best access to the pus collection using a no. 11 scalpel blade
3. A tongue blade or metal elevator is placed behind the lid to protect the globe; a chalazion clamp may stabilize the lesion
4. Express pus, apply direct pressure with gauze for hemostasis (5–10 minutes)
5. If significant cellulitis: send pus for culture and sensitivity
6. Do not suture skin in acute bacterial infection; consider systemic antibiotics for significant cellulitis

• Oral anti-staphylococcal antibiotic
• Daily follow-up until cellulitis resolves and pus is not reaccumulating
• Reassess at 2–3 weeks (swelling may persist for several weeks)

Complications

• Preseptal cellulitis — most common complication; treat as per cellulitis protocol
• Spread of infection — rare
• Lacrimal drainage system damage — if I&D performed near medial canthus
• Recurrence — associated with chronic blepharitis or acne rosacea; consider chronic low-dose doxycycline (20–50 mg/day) for recurrent cases

Key Points

• Hordeolum = acute staphylococcal abscess of an eyelid gland; chalazion = chronic lipogranuloma
• Most respond to warm compresses + topical antibiotics within a week
• I&D is reserved for failure, significant pain, or cellulitis
• Always exclude sebaceous carcinoma in recurrent or atypical cases (send specimens to pathology)
• Medial canthal lesions → refer, do not drain (dacryocystitis risk; cavernous sinus spread)