Management of Stye (Hordeolum)
The primary treatment for a stye consists of warm compresses applied to the affected eyelid for 10-15 minutes, 3-4 times daily, combined with gentle eyelid cleansing and massage to promote drainage. 1
Understanding Styes
A stye (hordeolum) is a common, painful inflammation of the eyelid margin usually caused by bacterial infection affecting the oil glands of the eyelid. Styes can be classified as:
- External hordeolum (stye): Infection of the glands of Zeis or Moll at the eyelid margin
- Internal hordeolum: Infection of the meibomian glands deeper in the eyelid
Diagnosis
Key Clinical Features
- Localized, painful, erythematous swelling at the eyelid margin
- May have a visible pustule or point
- Tenderness to palpation
- Possible eyelid edema
Associated Findings
- Check for signs of blepharitis (inflammation of eyelid margins)
- Assess for underlying conditions like rosacea or atopic dermatitis
- Evaluate for multiple or recurrent styes, which may suggest underlying conditions
Treatment Algorithm
First-Line Treatment
Warm compresses:
- Apply to affected eyelid for 10-15 minutes
- Repeat 3-4 times daily
- Helps to promote drainage and relieve pain
Eyelid hygiene:
- Gentle cleansing of eyelid margins with diluted baby shampoo or commercial eyelid cleanser
- Remove any crusts or debris
Gentle massage:
- After warm compress application
- Helps express the contents of the infected gland
Second-Line Treatment
If no improvement after 48-72 hours or signs of spreading infection:
- Topical antibiotics: Apply bacitracin or erythromycin ointment to the eyelid margins 1-2 times daily 1
- Continue warm compresses and eyelid hygiene
Third-Line Treatment
For moderate to severe cases or those not responding to topical antibiotics:
- Combination antibiotic/steroid treatments such as tobramycin/dexamethasone or loteprednol etabonate 0.5%/tobramycin 0.3% 1
- Note: Loteprednol has a lower risk of increasing intraocular pressure compared to dexamethasone
Fourth-Line Treatment
For persistent styes (>2 months) that develop into chalazia:
- Referral to ophthalmologist for possible:
- Intralesional steroid injection
- Incision and curettage 1
Special Considerations
When to Refer
- Stye persisting >2 months
- Signs of orbital cellulitis (fever, severe pain, proptosis, vision changes)
- Recurrent styes (may indicate underlying condition)
- Immunocompromised patients
- Aggressive infections with signs of systemic toxicity 1
Prevention of Recurrence
- Regular eyelid hygiene
- Complete removal of eye makeup before sleep
- Treatment of underlying conditions (blepharitis, rosacea)
- Avoid sharing towels or washcloths
- Consider replacing contact lenses and case after resolution if applicable 1
Evidence Quality
The evidence for non-surgical interventions in the treatment of hordeola is limited. Cochrane reviews have found no high-quality randomized controlled trials specifically addressing the treatment of internal hordeola 2, 3. Despite this lack of evidence, clinical practice guidelines consistently recommend warm compresses and eyelid hygiene as first-line treatment, with antibiotics reserved for cases with signs of spreading infection.
The American Academy of Ophthalmology's recommendations, as summarized in Praxis Medical Insights, provide the most comprehensive guidance for management, emphasizing conservative measures before moving to pharmacological interventions 1.
Pitfalls to Avoid
- Don't incise and drain at home - this should only be done by a healthcare professional
- Don't squeeze the stye - improper manipulation can spread infection
- Don't use contact lenses until the stye resolves
- Don't ignore recurrent styes - may indicate underlying conditions requiring evaluation
- Don't confuse with sebaceous cell carcinoma - persistent unilateral lesions warrant further investigation
Following this structured approach to the management of styes will lead to resolution in most cases while minimizing complications and recurrence.