Stye (Hordeolum) and Chalazion: Treatment Guide

Definitions and Key Differences

External Hordeolum (Stye):

Chalazion:

Treatment

1. Warm Compresses (Both Conditions - First Line)

• Apply warm compresses for 10-15 minutes, 4 times per day with gentle massage over the lesion
• One practical method: fill a sink with hot water and alternate wet washcloths for 15-20 minutes
• This promotes spontaneous drainage for hordeola and helps unclog meibomian glands in chalazia

2. Topical Antibiotics (Primarily for Hordeolum)

• Erythromycin ophthalmic ointment - most commonly recommended; apply b.i.d. to the eyelid margin for 7-10 days
• Bacitracin or tobramycin ointment - b.i.d. for 1-2 weeks
• For chalazion, a short course of topical antibiotic/steroid combination (e.g., neomycin/polymyxin B/dexamethasone ointment b.i.d. for 1-2 weeks) may help
• Monitor IOP if using topical steroids

3. Eyelid Hygiene (Especially for Chalazion)

• Eyelid scrubs at the lid margins nightly - use commercially available ocular cleansing pads or diluted baby shampoo (50:50 with water) applied with a cotton swab or washcloth
• Addresses associated blepharitis, which is a common predisposing factor

4. Eyelash Removal

• Removing the offending eyelash can be considered for external hordeolum to facilitate drainage

5. Incision and Drainage

• If a visible pustule is present, it can be nicked with a 25-gauge needle to express pus - this produces a faster cure
• The lid can be inverted to find and nick a pustule on the inner surface (for internal hordeolum)
• More formal I&D if unresponsive to conservative therapy
• If worsening cellulitis develops, manage as preseptal cellulitis and refer to ophthalmology

• Incision and curettage (I&C) is performed if it fails to resolve after 3-4 weeks of medical therapy and the patient desires intervention
• Approach: through the inner (conjunctival) surface of the eyelid using a chalazion clamp, no. 15 blade, and curette
• All excised chalazia (especially recurrent or atypical ones) should be sent for histopathology to rule out sebaceous carcinoma

• Chalazion that has recently drained through skin (risk of "buttonhole" defect)
• Markedly inflamed or crusted skin
• Anticoagulated patient (relative)
• Location near the lacrimal punctum - refer to ophthalmology

6. Intralesional Steroid Injection (Chalazion)

• Used as an alternative or adjunct to surgery
• Triamcinolone acetonide 40 mg/mL, 0.2-1.0 mL mixed 1:1 with 2% lidocaine with epinephrine
• Injected through the conjunctival (inner) surface with a 30-gauge needle after topical anesthetic drops (tetracaine)
• Alternative steroids: betamethasone sodium phosphate/acetate 6 mg/mL, or dexamethasone sodium phosphate 4 mg/mL
• Caution: Risk of permanent skin depigmentation or atrophy, especially in dark-skinned individuals. Rarely, vigorous injection can cause retrograde intra-arterial infiltration and central retinal artery occlusion. Discuss off-label use with patient.

7. Systemic Antibiotics

• Reserved for cases with significant surrounding cellulitis
• Use antistaphylococcal agents: dicloxacillin, cephalosporins
• For multiple/recurrent chalazia or associated ocular rosacea: doxycycline 20-50 mg orally daily to b.i.d. (low-dose for its anti-inflammatory and antibacterial properties)

Follow-up

• Patients are not routinely seen after starting medical therapy unless the lesion persists beyond 3-4 weeks
• Recurrent, large, or atypical chalazia in older patients warrant biopsy to exclude sebaceous carcinoma

Red Flags / When to Refer to Ophthalmology

Differential Diagnosis to Keep in Mind

• Preseptal cellulitis - diffuse eyelid erythema/edema/warmth
• Sebaceous carcinoma - recurrent, atypical, older patient
• Pyogenic granuloma - deep red pedunculated conjunctival lesion; treat with topical antibiotic-steroid combo
• Dacryocystitis - swelling at medial canthus, not lateral lid
• Forniceal foreign body - especially in contact lens wearers