Treatment of Styes (Hordeolum)
When to Treat a Stye
A stye should be treated immediately with warm compresses as first-line therapy, with antibiotics reserved for cases with moderate to severe inflammation, systemic symptoms, or failure to improve with conservative management.
Initial Assessment and Classification
Styes (hordeola) can be classified as:
- External hordeolum: Infection of the glands of Zeis or Moll at the eyelid margin
- Internal hordeolum: Infection of the meibomian glands deeper in the eyelid
Treatment Algorithm Based on Severity
Mild Cases (Most Common)
- Minimal redness
- Localized swelling
- Minimal pain
- No systemic symptoms
Moderate Cases
- Significant redness and swelling
- Moderate pain
- Purulent discharge
- No systemic symptoms
Severe Cases
- Marked inflammation
- Severe pain
- Spreading erythema beyond the eyelid
- Systemic symptoms (fever, malaise)
- Failure to respond to initial therapy
Treatment Recommendations
First-Line Treatment for All Styes
- Warm compresses: Apply to affected eyelid for 10-15 minutes, 4 times daily 1
- Gentle lid hygiene: Clean eyelid margins with mild soap or commercial lid scrubs
When to Add Antibiotics
Add topical antibiotics when:
- Moderate to severe inflammation is present
- Purulent discharge is evident
- No improvement after 48-72 hours of warm compresses
Recommended topical antibiotics:
- Fluoroquinolones (e.g., ofloxacin 0.3%, ciprofloxacin 0.3%) 2
- Erythromycin or bacitracin ointment applied to the lid margin 2-3 times daily 2
When to Consider Oral Antibiotics
Add oral antibiotics when:
- Severe inflammation with spreading erythema (>5 cm from the eyelid margin)
- Systemic symptoms (fever >38.5°C, heart rate >110 beats/minute) 1
- Immunocompromised patients
- Failed topical therapy
Recommended oral antibiotics:
- Dicloxacillin or cephalexin for methicillin-susceptible S. aureus
- Doxycycline, clindamycin, or SMX-TMP if MRSA is suspected 1
When to Refer for Surgical Drainage
Consider referral for incision and drainage when:
- Stye persists for >1 week despite appropriate medical therapy
- Large, pointing abscess has formed
- Severe pain or visual disturbance
- Recurrent styes in the same location
Special Considerations
Red Flags Requiring Urgent Referral
- Visual acuity changes
- Severe pain disproportionate to examination findings
- Proptosis or limitation of eye movements
- Spreading cellulitis or orbital involvement
- Immunocompromised patient
Evidence Quality and Limitations
The evidence for stye treatment is limited, with few high-quality randomized controlled trials. A Cochrane review found no randomized controlled trials specifically evaluating treatments for internal hordeola 3, 4. Treatment recommendations are largely based on expert consensus and clinical experience.
Common Pitfalls to Avoid
- Premature discontinuation of warm compresses (continue until resolution)
- Inappropriate use of corticosteroids (avoid in active infection)
- Squeezing or attempting to manually drain the stye (increases risk of spreading infection)
- Delaying referral for persistent or worsening symptoms
Monitoring and Follow-up
- Most styes resolve within 7-10 days with appropriate treatment
- If no improvement after 48-72 hours of initial therapy, reassess and consider antibiotic therapy
- If no improvement after 7 days of comprehensive therapy, consider referral for possible incision and drainage
Remember that recurrent styes may indicate underlying conditions such as blepharitis, diabetes, or immunosuppression that should be addressed to prevent future occurrences.