Initial Treatment for Hordeolum
The initial treatment for hordeolum (stye) should be warm compresses and eyelid hygiene, applied for several minutes, 1-2 times daily. 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
Clinical Characteristics vs. Chalazion
| Characteristic | Hordeolum | Chalazion |
|---|---|---|
| Onset | Acute | Gradual |
| Pain | Painful | Usually painless |
| Appearance | Red, swollen, pointed | Firm, round nodule |
| Etiology | Bacterial infection | Retained secretions |
Treatment Algorithm
First-Line Treatment
Warm compresses:
- Apply to eyelids for several minutes, 1-2 times daily
- Options include hot tap water on a clean washcloth, commercial heat pack, or homemade bean/rice bag
- Caution: Avoid temperatures that could burn the skin
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 for anterior blepharitis
Second-Line Treatment
If no improvement with warm compresses and eyelid hygiene:
- Topical antibiotic ointment (bacitracin or erythromycin):
- Apply to eyelid margins 1+ times daily
- Continue for a few weeks as needed 1
Third-Line Treatment
For large, painful hordeola that don't respond to conservative treatment:
- Incision and drainage may be necessary
- Systemic antibiotics may be considered for cases with spreading infection or systemic symptoms 1
Monitoring and Follow-up
Most hordeola are self-limiting and resolve within 1-2 weeks with conservative treatment. However, monitor for:
- Resolution of symptoms
- Development of complications
- Recurrence (may indicate underlying conditions)
Indications for Referral
Refer patients to an ophthalmologist 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
Special Considerations
Underlying Conditions
Recurrent hordeola may indicate:
- Meibomian gland dysfunction
- Blepharitis
- In children: chronic blepharokeratoconjunctivitis
- In elderly patients with recurrent lesions: consider sebaceous carcinoma
Potential Pitfalls
- Failing to recognize that untreated hordeola can progress to chalazia
- Using compresses that are too hot and may burn the skin
- Aggressive eyelid manipulation in patients with advanced glaucoma or filtering procedures should be avoided 1
Evidence Quality
The evidence for non-surgical interventions for acute internal hordeolum is limited. Cochrane reviews found no randomized controlled trials specifically addressing the effectiveness of non-surgical treatments for internal hordeola 2, 3. However, clinical practice guidelines consistently recommend warm compresses and eyelid hygiene as first-line treatment.