What is the treatment for hordeolum?

Treatment of Hordeolum

The first-line treatment for hordeolum (stye) is warm compresses applied to the affected eyelid for several minutes, 1-2 times daily, combined with eyelid hygiene. 1

Understanding Hordeolum

Hordeolum is an acute, painful inflammation of the eyelid margin, typically caused by bacterial infection affecting the oil glands of the eyelid. It can be classified as:

• External hordeolum (stye): Affects the glands of Zeis or Moll associated with eyelash follicles
• Internal hordeolum: Affects the meibomian gland in the tarsal plate

Characteristics that distinguish hordeolum from chalazion include:

• Onset: Acute (vs. gradual for chalazion)
• Pain: Painful (vs. usually painless for chalazion)
• Appearance: Red, swollen, pointed (vs. firm, round nodule for chalazion)
• Etiology: Bacterial infection (vs. retained secretions for chalazion) 1

Treatment Algorithm

Step 1: Conservative Management (First-line)

• Warm compresses: Apply to affected eyelid for several minutes, 1-2 times daily
  • Use hot tap water on a clean washcloth, commercial heat pack, or homemade bean/rice bag
  • Caution: Avoid temperatures that could burn the skin 1
• Eyelid hygiene: Gentle cleansing of eyelid margins to remove crusting
  • Use diluted baby shampoo or commercial eyelid cleaner on a cotton ball/swab
  • Hypochlorous acid 0.01% cleaners have strong antimicrobial effects 1

Step 2: Topical Antibiotics (If needed)

• Apply antibiotic ointment (bacitracin or erythromycin) to eyelid margins 1+ times daily
• Continue for a few weeks as needed 1

Step 3: For Persistent or Severe Cases

• Incision and drainage: May be necessary for large, painful hordeola that don't respond to conservative treatment
• Systemic antibiotics: Consider for cases with spreading infection or systemic symptoms 2

Special Considerations

Potential Complications

• If left untreated, hordeola can:
  • Progress to chalazia
  • Spread infection to adjacent tissues
  • In rare cases, lead to eyelid necrosis or cellulitis 3

When to Refer to an Ophthalmologist

Refer patients if they experience:

• Visual loss
• Moderate or severe pain
• Severe or chronic redness
• Recurrent hordeola in the same location
• No improvement after 4-6 weeks of conservative treatment 1

Recurrent Hordeola

• May indicate underlying conditions such as:
  • Meibomian gland dysfunction
  • Blepharitis
  • In children: chronic blepharokeratoconjunctivitis 1
• In elderly patients with recurrent lesions in the same location, consider sebaceous carcinoma 1

Evidence Quality and Limitations

The evidence for hordeolum treatment is limited:

• No high-quality randomized controlled trials specifically evaluating non-surgical interventions for acute internal hordeola 4, 5
• One small study found no difference between antibiotic ophthalmic solution and placebo after incision and curettage 6
• Most recommendations are based on expert consensus and clinical experience

Common Pitfalls to Avoid

• Using excessively hot compresses: Can burn delicate eyelid skin
• Aggressive squeezing or manipulation: May worsen inflammation or spread infection
• Premature discontinuation of treatment: Complete the full course to prevent recurrence
• Missing underlying conditions: Address contributing factors like blepharitis
• Aggressive eyelid manipulation in patients with advanced glaucoma: Can be harmful 1

Remember that most hordeola will resolve spontaneously within 7-10 days with appropriate conservative management, but proper treatment can speed resolution and prevent complications.