Hordeolum and Stye

Introduction

Background

A hordeolum (ie, stye) is a localized infection or inflammation of the eyelid margin involving hair follicles of the eyelashes (ie, external hordeolum) or meibomian glands (ie, internal hordeolum). Achalazion is a painless granuloma of the meibomian glands.

A hordeolum usually is painful, erythematous, and localized. It may produce edema of the entire lid. Purulent material exudes from the eyelash line in external hordeola, while internal hordeola suppurate on the conjunctival surface of eyelid.

Pathophysiology

Staphylococcus aureus is the infectious agent in 90-95% of cases of hordeolum.

An external hordeolum arises from a blockage and infection of Zeiss or Moll sebaceous glands. An internal hordeolum is a secondary infection of meibomian glands in the tarsal plate. Both types can arise as a secondary complication of blepharitis.

Untreated, the disease may spontaneously resolve or it may progress to chronic granulation with formation of a painless mass known as a chalazion. Chalazia can be quite large and can cause visual disturbance by deforming the cornea. Generalized cellulitis of the eyelid may occur if an internal hordeolum is untreated.

Most morbidity is secondary to improper drainage. Proper technique and drainage precautions are described inTreatment.

Frequency

United States

Exact incidence of the disease is unknown, but it is a common entity.

International

No difference exists between US and international occurrence.

Sex

No sexual predilection exists.

Age

A slight increase in incidence is observed in the third to fifth decades of life.

Clinical

History

• Patients usually complain of a localized painful swelling on one eyelid.
• In some cases, the complaint may start as a generalized edema and erythema of the lid that later becomes localized.
• A history of similar problems is common.
• Constitutional signs and symptoms are inconsistent with a hordeolum diagnosis. In extreme cases, the infection can spread to involve the entire lid and even the periorbital tissues. Such cases do not respond to normal hordeolum management and must be managed as periorbital cellulitis.

Physical

Completely examine the area around the orbit, the eye, and the conjunctival surface. Carefully inspect the underside of the eyelid to avoid missing an internal hordeolum.

• Examination reveals a localized tender area of swelling with a pointing eruption either on the internal or on the external side of eyelid. See the images below.
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    Hordeolum pointing internally

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    Internal side of the same hordeolum

• Occasionally, the hordeolum points on both sides.
• Infection of conjunctiva is a common secondary finding.
• Examination of preauricular nodes can help to identify spread of the disease beyond a simple hordeolum. Nodes should not be swollen in patients with a simple hordeolum.
• No intraocular pathology should be found.
• Presence of fever or distant nodes indicates systemic disease.

Causes

• Staphylococcal organisms are the most common causes of eyelid infections, but other organisms may be involved.
• Hordeola are found more frequently in persons who have the following:
• Diabetes
• Other debilitating illness
• Chronic blepharitis
• Seborrhea
• High serum lipids (High lipid levels increase the blockage rate of sebaceous glands, but lowering of serum lipid levels in these patients has not decreased frequency of recurrence.)

Differential Diagnoses

Chalazion
Conjunctivitis
Corneal Abrasion

Other Problems to Be Considered

Blepharitis
Eyelid neoplasms

Workup

Laboratory Studies

• No laboratory studies are indicated for hordeolum.
• Colonization with noninvasive bacteria is common, and bacterial cultures of material from the area generally do not correlate with clinical improvement.
• Conjunctival bacteria culture results are positive in as many as 70% of asymptomatic persons with a hordeolum. S aureus is the most likely organism discovered, but cultures of the eyelid are more likely to obtain Staphylococcus epidermidis. For this reason, eye cultures are of little clinical value.
• Blood tests are of no value in a simple hordeolum, but generalized eyelid cellulitis requires a more complete evaluation. If the infection is not well localized, a CBC and blood culture are required, and ophthalmologic consultation is indicated

Treatment

Emergency Department Care

• Drainage of a hordeolum
  • Perform drainage with stab incisions at the site of pointing using an 18-gauge needle or a #11 blade. External incisions lead to scarring, so making external eyelid incisions or punctures is inadvisable, unless the hordeolum already is pointing externally.
  • A large abscess may have multiple pockets and require multiple stabs.
  • Internal incisions should be made vertically to minimize the area of cornea swept by a scar during blinking; external incisions should be made horizontally for optimal cosmesis.
  • Hold the lesion with a chalazion clamp.
  • To avoid disrupting normal growth of lashes, do not make incisions along eyelash margins.
  • Leave the incision open with a clean margin.
  • When draining a lesion that points both externally and internally, make the incision internally and as far as possible from the site of external pointing. Combined overlying internal and external drainage increases the risk of later fistulae through the lid.
  • Do not inject local anesthesia directly into the hordeolum; inject along the lid margins in a line above the upper tarsus or below the lower tarsus.
  • Do not attempt to remove all seemingly purulent material if acute inflammation is present; excessive loss of tarsal tissue and lid deformity may result.
• Hordeola usually are self-limited even without drainage. Most hordeola eventually point and drain by themselves.
• Warm soaks (qid for 15 min) are the mainstays of treatment.
• Antibiotics are indicated only when inflammation has spread beyond the immediate area of the hordeolum.
  • Topical antibiotics may be used for recurrent lesions and for those that are actively draining. Topical antibiotics do not improve the healing of surgically drained lesions.¹
  • Systemic antibiotics are indicated if signs of bacteremia are present or if the patient has tender preauricular lymph nodes.
• Surgical drainage of pointed lesions speeds the healing process.
  • If the lesion points at a lash follicle, removal of that one eyelash hair may promote drainage and healing.
  • Exercise caution when removing a lash, because removal of multiple lashes may result in disfigurement.

Consultations

• If the patient does not respond to conservative therapy (ie, warm compresses, antibiotics) within 2-3 days, consult with an ophthalmologist.
• Consultation with an ophthalmologist is recommended prior to drainage of large lesions that may have a higher likelihood of complications.

Medication

Start therapy for hordeolum with a topical treatment. Progress to systemic therapy only if signs and symptoms of severe infection are found.

Antibiotics

Topical antibiotics are useful for control of staphylococcal infections in eyelids and nares.

Bacitracin ophthalmic ointment (AK-Tracin)

Prevents transfer of mucopeptides into growing cell wall; inhibits bacterial cell wall synthesis.

Tobramycin ophthalmic solution or ointment (Tobrex, AKTob)

Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, which results in a defective bacterial cell membrane; available as solution, ointment, and lotion

Erythromycin (EES, E-Mycin, Ery-Tab)

First-choice treatment when systemic therapy is indicated; also indicated for treatment of infections caused by susceptible strains of microorganisms, including S aureus.

Dicloxacillin (Dycill, Dynapen)

For treatment of infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when a staphylococcal infection is suspected.

Tetracycline (Sumycin)

Treats susceptible bacterial infections of both gram-positive and gram-negative organisms as well as infections caused by mycoplasmal, chlamydial, and rickettsial organisms; inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s) of susceptible bacteria

Cloxacillin (Cloxapen, Tegopen)

For treatment of infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when a staphylococcal infection is suspected.

Follow-up

Further Outpatient Care

• All patients with hordeolum should seek follow-up care with an ophthalmologist within 1-2 weeks if the condition is not resolved completely with conservative management.

Inpatient & Outpatient Medications

• Patients should use warm compresses 3-4 times per day.

Deterrence/Prevention

• Cleaning of eyelashes or removal of a few affected lashes may improve drainage and reduce recurrence.

Complications

• The most frequent complication of hordeolum is progression to a chalazion that causes cosmetic deformity, corneal irritation, or the need for surgical removal.
• Complications of improper drainage are disruption of lash growth, lid deformity, or lid fistula.
• Generalized eyelid cellulitis may develop if an internal hordeolum is untreated.

Prognosis

• Spontaneous healing is common.
• Frequent recurrences are common.
• Progression to systemic infection is rare; only a few case reports appear in the current literature.

Patient Education

• Instruct patients on proper use of warm compresses and antibiotic use as described above.
• For prevention, educate patients about lid hygiene.
• Instruct patients not to squeeze a stye, because infection may spread to adjacent tissues.
• For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education articles Chalazion (Lump in Eyelid) and Sty.