What is the treatment for multiple eyelid styes (hordeolum)?

Treatment for Multiple Eyelid Styes (Hordeolum)

The most effective treatment for multiple eyelid styes involves warm compresses (10-15 minutes, 3-4 times daily), eyelid hygiene with gentle massage, and topical antibiotic ointment such as bacitracin or erythromycin for signs of infection. 1

First-Line Treatment Approach

1. Warm Compresses

   • Apply for 10-15 minutes, 3-4 times daily
   • Helps soften adherent debris and warm meibomian secretions
   • Facilitates drainage of the infected glands
   • Options for effective heat retention include:
     • Warm washcloths (need frequent reheating)
     • Hard-boiled eggs (better heat retention)
     • Commercial heat-generating products 1, 2

2. Eyelid Hygiene

   • Clean eyelid margins with gentle cleansers
   • Hypochlorous acid (0.01%) cleansers have strong antimicrobial effects for anterior blepharitis
   • Vertical eyelid massage to express meibomian secretions 1

Second-Line Treatment

• Topical Antibiotics
  • Bacitracin or erythromycin ointment
  • Apply to the eyelid margin when signs of infection are present
  • Helps prevent secondary infection 1, 3

Third-Line Treatment for Moderate to Severe Cases

• Combination Antibiotic/Steroid Topical Treatment

  • Consider for moderate to severe inflammation
  • Monitor for potential side effects including increased intraocular pressure and cataract formation 1

• Oral Antibiotics

  • Consider doxycycline or azithromycin for moderate-severe cases
  • Use with caution, particularly azithromycin due to potential cardiac risks
  • Typically reserved for cases unresponsive to topical treatment 1

Fourth-Line Treatment for Persistent Styes

• Intralesional Steroid Injection
• Incision and Curettage
  • Consider for persistent (>2 months) or large chalazia 1

Important Clinical Considerations

• Follow-up Timing

  • Reassess treatment response in 2-4 weeks for moderate to severe cases 1

• Warning Signs Requiring Specialist Referral

  • Visual changes
  • Severe eyelid swelling unresponsive to initial treatment
  • Persistent symptoms despite appropriate therapy
  • Suspected malignancy (especially with unilateral, recurrent, or atypical presentation)
  • Corneal involvement
  • Cicatricial changes in the conjunctiva 1

• Consider Biopsy When

  • Marked asymmetry between eyes
  • Resistance to standard therapy
  • Unifocal recurrent chalazia
  • Loss of normal eyelid margin anatomy
  • Focal lash loss (madarosis) 1

Prevention Strategies

• Practice good eyelid hygiene consistently
• Remove eye makeup completely before sleeping
• Consider dietary modifications (such as a Mediterranean diet)
• Discontinue contact lens wear until symptoms resolve
• Treat any underlying conditions (seborrheic dermatitis, rosacea, eczema, thyroid dysfunction) 1

Evidence Quality Assessment

The current treatment recommendations are primarily based on clinical guidelines from the American Academy of Ophthalmology 1. It's worth noting that systematic reviews have found a lack of high-quality randomized controlled trials specifically evaluating treatments for internal hordeolum 4, 5. This highlights a gap in the evidence base, though the current recommendations represent the best available clinical practice.

Some emerging evidence suggests acupuncture may provide benefits for acute hordeolum, but the certainty of this evidence is low to very low, with studies primarily conducted in Chinese populations, limiting generalizability 6.