What is the management of an infected stye (hordeolum)?

Management of Stye (Hordeolum)

Warm compresses applied 3-4 times daily for 10-15 minutes are the first-line treatment for styes, with topical antibiotics reserved for cases with significant surrounding cellulitis or lack of improvement after 48 hours.

Classification and Diagnosis

A stye (hordeolum) is an acute, localized infection of the eyelid that can be classified as:

• External hordeolum: Infection of the glands of Zeis or Moll (sebaceous glands at the eyelid margin)
• Internal hordeolum: Infection of the meibomian glands (deeper in the eyelid)

Common symptoms include:

• Localized eyelid pain, swelling, and redness
• Tenderness to touch
• Sensation of a foreign body in the eye
• Tearing
• Crusting along the eyelid margin

The most common causative organism is Staphylococcus aureus, though other bacteria may be involved.

Treatment Algorithm

1. First-Line Treatment: Conservative Management

• Warm compresses: Apply to the affected area for 10-15 minutes, 3-4 times daily 1

  • Facilitates spontaneous drainage
  • Improves blood circulation to the area
  • Helps resolve inflammation

• Gentle lid hygiene: Clean the eyelid margins with mild soap and water or commercial lid scrubs

• Avoid eye makeup and contact lenses until the infection resolves

2. Pharmacological Management

• Topical antibiotics (if significant surrounding cellulitis or no improvement after 48 hours):

  • Bacitracin ointment: Apply a small amount (equal to the surface area of the tip of a finger) to the affected area 1-3 times daily 2
  • Erythromycin ophthalmic ointment
  • Hydrochloric levofloxacin (for more severe cases) 3

• Oral antibiotics (for severe cases with extensive surrounding cellulitis or systemic symptoms):

  • Consider coverage for MRSA if prevalent in your area:
    • Clindamycin 300-450 mg orally three times daily
    • Trimethoprim-sulfamethoxazole (TMP-SMX)
    • Doxycycline 100 mg twice daily 4

3. Surgical Management

• Incision and drainage: Consider if the stye is large, painful, and pointing (showing a visible collection of pus)
  • This should be performed by an experienced clinician
  • Usually reserved for cases that don't respond to conservative treatment after 48-72 hours

Special Considerations

Recurrent Styes

For patients with recurrent styes, implement preventive measures:

• Hygiene measures 1:

  • Regular handwashing with soap and water
  • Avoid touching or rubbing eyes
  • Replace eye makeup every 3-6 months
  • Clean contact lenses properly

• Decolonization strategies for recurrent infections 1:

  • Nasal mupirocin twice daily for 5-10 days
  • Topical body decolonization with chlorhexidine washes

When to Refer

Refer to an ophthalmologist if:

• No improvement after 7 days of treatment
• Recurrent styes
• Visual changes
• Severe pain or spreading erythema
• Concern for orbital cellulitis (proptosis, limited eye movement, vision changes)

Evidence Quality Assessment

The evidence for stye management is limited, with no randomized controlled trials specifically addressing acute internal hordeolum treatment 5, 6. Most recommendations are based on expert opinion and clinical experience rather than high-quality evidence.

Pitfalls to Avoid

1. Squeezing or popping the stye can spread infection and worsen inflammation

2. Delaying treatment for severe infections with significant cellulitis or systemic symptoms

3. Failing to distinguish between a stye and a chalazion (non-infectious lipogranulomatous inflammation of the meibomian gland)

4. Overlooking signs of orbital cellulitis (fever, proptosis, ophthalmoplegia, vision changes) which requires immediate referral and IV antibiotics

5. Continuing contact lens wear during active infection, which can lead to corneal complications

By following this structured approach to stye management, most cases will resolve within 7-10 days with minimal complications.