What is the treatment for a hordeolum (stye)?

Treatment Guidelines for Hordeolum (Stye)

The first-line treatment for hordeolum consists of warm compresses applied to the affected eyelid for 10-15 minutes, 3-4 times daily, combined with gentle eyelid hygiene and massage. 1

Understanding Hordeolum

A hordeolum, commonly known as a stye, is a painful, localized inflammation of the eyelid margin caused by bacterial infection affecting the oil glands of the eyelid. It can be classified as:

• Internal hordeolum: Affects the meibomian gland in the tarsal plate
• External hordeolum: Affects the glands of Zeis or Moll associated with eyelash follicles

Treatment Algorithm

First-Line Treatment

• Warm compresses: Apply for 10-15 minutes, 3-4 times daily
  • Helps to increase blood circulation to the area
  • Promotes spontaneous drainage
  • Softens and liquefies the material in the infected gland
• Eyelid hygiene: Gentle cleansing of the eyelid margins
• Gentle massage: After applying warm compresses to help express the contents of the gland 1

Second-Line Treatment

• Topical antibiotics: Consider adding if signs of significant infection or risk of secondary infection
  • Bacitracin or erythromycin ointment applied to the lid margin 1
  • Azithromycin ophthalmic solution has shown efficacy in treating internal hordeolum 2

Third-Line Treatment

• Combination antibiotic/steroid topical treatments: For moderate to severe cases
  • Loteprednol etabonate/tobramycin combinations have shown efficacy with less risk of intraocular pressure rise 1

Fourth-Line Treatment

• Incision and curettage: For persistent (>2 months) or large hordeola
  • Note: A study showed no significant benefit of adding antibiotics after incision and curettage 3

Special Considerations

For Recurrent Hordeola

• Nasal decolonization: Mupirocin applied twice daily for 5-10 days 1
• Body decolonization: Consider chlorhexidine antiseptic solution for 5-14 days or dilute bleach baths (1 teaspoon per gallon of water, 15 minutes twice weekly for 3 months) 1

Prevention Strategies

• Maintain good eyelid hygiene
• Remove eye makeup completely before sleeping
• Treat underlying conditions that may contribute to recurrence
• Discontinue contact lens wear until symptoms resolve 1

Evidence Quality Assessment

The current evidence for non-surgical interventions for hordeolum is limited. Cochrane reviews from 2013 and 2017 found no randomized controlled trials evaluating the effectiveness of non-surgical treatments for acute internal hordeolum 4, 5. Despite this lack of high-quality evidence, clinical practice guidelines from the American Academy of Ophthalmology recommend the step-wise approach outlined above 1.

When to Refer

Consider referral to an ophthalmologist for:

• Visual changes
• Corneal involvement
• Severe eyelid swelling unresponsive to initial treatment
• Suspected malignancy
• Cicatricial changes in the conjunctiva 1

Biopsy Considerations

Consider biopsy for cases with:

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

While most hordeola will resolve spontaneously with conservative management, proper treatment can help reduce symptoms, prevent complications, and minimize recurrence.