Stye (Hordeolum)

Upper eyelid hordeolum showing erythema and swelling

Definition

A hordeolum (stye) is an acute, tender infection of the oil glands of the eyelid. There are two types:

Type	Gland affected	Location
External hordeolum	Gland of Zeis (sebaceous) or Moll (sweat) at the eyelash follicle	Eyelid margin
Internal hordeolum	Meibomian gland	Posterior tarsal surface (inside eyelid)

It is distinct from a chalazion, which is a chronic, sterile, granulomatous blockage of a meibomian gland - usually non-tender and located in the body of the eyelid rather than the margin. A chalazion can evolve from an untreated hordeolum.

The Wills Eye Manual, p. 381-382
Rosen's Emergency Medicine, p. 893

Pathophysiology

Obstruction of the gland orifice leads to stasis of secretions, followed by bacterial invasion and localized purulent (pyogenic) inflammation. The most common causative organism is Staphylococcus aureus. The infection can occasionally progress to preseptal cellulitis.

Clinical Features

Acute onset painful, red, swollen lump on the eyelid
Localized tenderness and erythema
May point and discharge mucopurulent material
Associated eyelid swelling; sometimes associated blepharitis

Internal hordeolum presents similarly but with pain and erythema visible on the posterior (conjunctival) surface of the eyelid when it is everted.

Differential Diagnosis

Condition	Key distinguishing feature
Chalazion	Nontender, chronic nodule in lid body, not at margin
Preseptal cellulitis	Diffuse eyelid erythema/edema, fever; may spread from hordeolum
Sebaceous carcinoma	Recurrent "chalazia," older patient, madarosis (lash loss) - must biopsy
Pyogenic granuloma	Fleshy red conjunctival lesion, often post-inflammatory
Forniceal foreign body	History of trauma or contact lens use

Workup

Diagnosis is clinical. No lab tests or imaging are typically needed.

Palpate the eyelid for a nodule
Evert the lid to assess the posterior surface (for internal hordeolum)
Slit lamp: evaluate meibomian glands, check for madarosis/ulceration to exclude malignancy in atypical or recurrent cases
Look for associated rosacea or blepharitis

Treatment

First-line (medical)

Warm compresses - at least 10 minutes, 4 times daily, with gentle massage over the lesion. This is the cornerstone of treatment and encourages drainage.
Eyelid hygiene - lid scrubs to reduce bacterial colonization.
Topical antibiotics (for active hordeolum or if draining):
- Bacitracin, tobramycin, or erythromycin ointment b.i.d. for 1-2 weeks
- Topical antibiotic/steroid combination (e.g., neomycin/polymyxin B/dexamethasone) may be used for chalazion component
If the lesion is centered around a lash follicle, epilation of the lash can enhance drainage.

Oral antibiotics

Add oral antibiotics if there is surrounding cellulitis or systemic signs
Doxycycline 20-50 mg daily (low dose, for anti-inflammatory effect) for recurrent lesions or associated meibomitis/ocular rosacea

Refractory or worsening cases

Incision and drainage (I&D) under local anesthesia:
- External hordeolum: incision through skin and orbicularis
- Internal hordeolum: incision through the tarsal conjunctiva

If it evolves into a chalazion (chronic, after 3-4 weeks)

Intralesional steroid injection: triamcinolone 40 mg/mL mixed 1:1 with 2% lidocaine with epinephrine (0.2-1.0 mL). Note: risk of skin depigmentation/atrophy (especially in darker skin) and rare retrograde arterial infiltration - discuss with patient.
Incision and curettage: send all excised tissue for pathology, especially recurrent or atypical lesions.
The Wills Eye Manual, p. 382-383

Complications

Chalazion - chronic granuloma if hordeolum doesn't resolve
Preseptal (periorbital) cellulitis - diffuse spread anterior to orbital septum
Orbital (post-septal) cellulitis - rare; more sinister: proptosis, ophthalmoplegia, pain on eye movement, visual loss - requires urgent imaging and IV antibiotics

Follow-up

Routine follow-up is not needed if the lesion responds to warm compresses.
Return if no improvement after 1-2 weeks, or sooner if worsening (especially if signs of spreading cellulitis develop).
Recurrent or atypical lesions in older patients warrant biopsy to exclude sebaceous cell carcinoma.

Key takeaway: Most styes resolve with warm compresses alone. Topical antibiotics are added for active infection or drainage; I&D is reserved for large or non-responding lesions. Any recurrent or atypical eyelid lesion should raise concern for malignancy.

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