Treatment of Hordeolum
The first-line treatment for hordeolum is warm compresses applied for 10-15 minutes, 3-4 times daily, combined with gentle eyelid massage and proper eyelid hygiene. 1
Understanding Hordeolum
A hordeolum (stye) is an acute, purulent inflammation of the eyelid margin usually caused by obstruction of the sebaceous glands of the eyelid. There are two types:
- External hordeolum (stye): Affects the glands of Zeis or Moll associated with eyelash follicles
- Internal hordeolum: Affects the meibomian gland in the tarsal plate
Treatment Algorithm
First-Line Treatment
- Warm compresses: Apply for 10-15 minutes, 3-4 times daily
- Helps liquefy thickened sebum
- Promotes drainage
- Reduces inflammation 1
- Gentle eyelid massage: After applying warm compresses to help express the contents of the affected gland
- Eyelid hygiene: Clean eyelid margins with a clean pad, cotton ball, cotton swab, or clean fingertip
- Focus on removing crusting from eyelashes
- Include vertical eyelid massage to express meibomian gland secretions 1
Second-Line Treatment
- Topical antibiotics: Consider adding if signs of blepharitis or risk of secondary infection
Third-Line Treatment
- Combination antibiotic/steroid topical treatment: For moderate to severe cases 1
- Oral antibiotics: Consider for severe or recurrent cases
- Dicloxacillin: 500 mg four times daily for adults
- Cephalexin: 500 mg four times daily for adults
- Clindamycin: 300-450 mg three times daily for adults 1
Fourth-Line Treatment
- Incision and drainage: For persistent hordeola that point or have localized fluctuance
- If diagnosed early, thrombosed external hemorrhoids are best managed by excision under local anesthesia 3
- Intralesional steroid injection: For persistent cases (>2 months) 1
Special Considerations
When to Refer to an Ophthalmologist
Refer patients with:
- Persistent styes (>2 weeks)
- Styes that develop into chalazia
- Suspected MRSA infections
- Visual changes
- Severe eyelid swelling
- Immunocompromised status 1
Prevention of Recurrence
- Maintain good eyelid hygiene
- Remove eye makeup completely
- Treat underlying conditions
- Discontinue contact lens wear until symptoms resolve
- Regular bathing and keeping draining wounds covered 1
Potential Complications
- Progression to chalazion
- Spread to adjacent glands and tissues
- Generalized eyelid cellulitis
- In rare cases, eyelid necrosis 4
Evidence Assessment
The evidence for non-surgical interventions for hordeolum is limited. Cochrane reviews found no randomized controlled trials specifically evaluating treatments for acute internal hordeolum 5, 6. One small study found that combined antibiotic ophthalmic solution was not more effective than placebo in the treatment of hordeolum after incision and curettage 7.
Despite the limited high-quality evidence, warm compresses remain the cornerstone of treatment based on clinical experience and expert consensus, with additional interventions added as needed based on severity and response to initial therapy.