Treatment of Hordeolum (Stye)
Warm compresses and eyelid hygiene are the first-line treatment for hordeolum, with antibiotic ointment reserved for cases that don't respond to conservative management. 1
Understanding Hordeolum
Hordeolum (stye) 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: Affects glands of Zeis or Moll associated with eyelash follicles
- Internal hordeolum: Affects meibomian gland in the tarsal plate
First-Line Treatment
Warm Compresses
- Apply warm compresses to affected eyelid for several minutes, 1-2 times daily 1
- Options include:
- Clean washcloth with hot tap water
- Commercial heat pack
- Homemade bean/rice bag heated in microwave
- Caution: Avoid temperatures that could burn skin 1
Eyelid Hygiene
- Gently cleanse eyelid margins to remove crusting using:
Second-Line Treatment
Topical Antibiotics
- Apply antibiotic ointment (bacitracin or erythromycin) to eyelid margins 1+ times daily
- Continue for a few weeks as needed 1
When to Consider Incision and Drainage
- For large, painful hordeola that don't respond to conservative treatment 1
Systemic Antibiotics
- Consider only for cases with spreading infection or systemic symptoms 1
Evidence Quality and Treatment Efficacy
Despite widespread recommendations for warm compresses and antibiotics, multiple Cochrane reviews (2010,2013,2017) found no randomized controlled trials evaluating non-surgical interventions for hordeolum 2, 3, 4. This highlights a significant gap between clinical practice and evidence-based medicine.
Complications and When to Refer
Untreated hordeola may lead to:
- Progression to chalazia
- Spread of infection to adjacent tissues
- Rarely, eyelid necrosis or cellulitis 1, 5
Refer patients who 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
Special Considerations
- Children: Recurrent hordeola may indicate unrecognized chronic blepharokeratoconjunctivitis requiring more aggressive treatment 1
- Elderly: Recurrent lesions in the same location should raise suspicion for sebaceous carcinoma 1
- Recurrent cases: May indicate underlying conditions such as meibomian gland dysfunction or blepharitis 1
Prevention
- Early intervention with warm compresses and lid hygiene
- Address underlying conditions that contribute to meibomian gland dysfunction
- Complete the treatment course
- Regular follow-up for patients with recurrent episodes 1
Treatment Pitfalls to Avoid
- Using compresses that are too hot (risk of skin burns)
- Failing to recognize that untreated hordeola can progress to chalazia
- Aggressive eyelid manipulation in patients with advanced glaucoma or filtering procedures 1