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Hordeolum

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Here is a comprehensive overview of hordeolum drawn from multiple authoritative sources:

Hordeolum (Stye)

External hordeolum - lower eyelid with visible redness and swelling
External hordeolum showing erythema and swelling of the lower eyelid

Definition

A hordeolum is an acute, tender infection of an eyelid gland, usually caused by Staphylococcus aureus (occasionally other Staphylococcus species). There are two types:
TypeGland InvolvedLocation
External hordeolum (stye)Gland of Zeis (sebaceous) or Moll (sweat glands) of the lash follicleLash line, points anteriorly through skin; often has a lash at its apex
Internal hordeolumMeibomian glandPustule on inner surface of the tarsal plate
A chalazion, by contrast, is a chronic, sterile lipogranulomatous inflammation of a meibomian gland - often nontender and may evolve from an unresolved hordeolum. - Tintinalli's Emergency Medicine, p. 1581

Epidemiology

External hordeola are common in children and young adults. Multiple lesions may be present, and occasionally an abscess can involve the entire lid margin. - Kanski's Clinical Ophthalmology, 10th ed.

Clinical Features

  • Pain, eyelid edema, and erythema
  • Small pustule at the eyelid margin (external) or on the inner tarsal surface (internal)
  • Tender swelling pointing toward the skin surface
  • Occasionally the abscess may involve the entire lid margin
  • Can be complicated by preseptal (periorbital) cellulitis if the infection spreads

Differential Diagnosis

ConditionKey Feature
ChalazionChronic, nontender, sterile; lipogranulomatous
Preseptal cellulitisDiffuse eyelid erythema, edema, warmth
Sebaceous carcinomaOlder patients, recurrent "chalazia," madarosis, lid thickening - must biopsy
Pyogenic granulomaBenign deep-red pedunculated lesion, often at site of prior chalazion
Forniceal foreign bodyEyelid swelling, especially in contact lens wearers
Red flag: A recurrent chalazion or hordeolum in the same location in an older patient should raise suspicion for sebaceous gland carcinoma. - Wills Eye Manual

Workup

  • Diagnosis is clinical - no additional testing needed in typical cases
  • History: prior eyelid lesions, ocular surgery/trauma
  • External exam: palpate for nodule, look for rosacea
  • Slit lamp: evaluate meibomian glands, evert eyelid, check for madarosis or ulceration (to rule out malignancy)

Treatment

First-Line (Conservative)

  1. Warm compresses - at least 10-15 minutes, 3-5 times per day - with gentle massage over the lesion. This normalizes flow from the obstructed gland.
  2. Topical antibiotics - bacitracin, erythromycin, or tobramycin ointment b.i.d. for 1-2 weeks; or topical fluoroquinolone drops (moxifloxacin or gatifloxacin)
  3. Epilation of the associated lash may be considered for external hordeolum

If No Improvement / Worsening

  1. Systemic antibiotics - indicated if significant surrounding cellulitis develops
  2. Incision and drainage (I&D) - by ophthalmologist if symptoms do not improve within 48 hours; do not attempt I&D in the ED - refer instead
  3. Chronic/recurrent cases - low-dose doxycycline 20-50 mg orally daily to b.i.d. (antibacterial and anti-inflammatory; also useful in ocular rosacea)

For Persistent Chalazion (>3-4 weeks)

  • Intralesional steroid injection (e.g., triamcinolone 40 mg/mL mixed 1:1 with 2% lidocaine with epinephrine, 0.2-1.0 mL)
  • Incision and curettage (I&C) - all excised chalazia should be sent for pathology
Note on steroid injection: Risk of permanent depigmentation or skin atrophy, especially in dark-skinned individuals. Rarely, vigorous injection can cause retrograde intra-arterial infiltration with central retinal artery occlusion. - Wills Eye Manual, p. 382-383

Complications

  • Preseptal (periorbital) cellulitis - most common complication; requires systemic antibiotics
  • Post-septal (orbital) cellulitis - rare but serious; presents with proptosis, ophthalmoplegia, pain with eye movement, chemosis, and visual changes - requires urgent CT imaging and IV antibiotics

Follow-Up

  • Most lesions are self-limited and resolve with warm compresses alone within days to weeks
  • Ophthalmology referral if no improvement within 48 hours or if systemic spread is suspected
  • Routine follow-up not needed after starting medical therapy unless the lesion persists beyond 3-4 weeks
Sources: Goldman-Cecil Medicine | Tintinalli's Emergency Medicine | Kanski's Clinical Ophthalmology 10th ed. | Wills Eye Manual | Rosen's Emergency Medicine
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