What to do for a worsening upper eyelid hordeolum (stye) that is not responding to topical antibiotics?

Management of Worsening Upper Eyelid Hordeolum Despite Topical Antibiotics

For a worsening upper eyelid hordeolum that is not responding to topical antibiotics, incision and drainage is recommended as the next step in management, along with warm compresses and consideration of oral antibiotics if there are signs of spreading infection.

First-Line Management (Continue These Measures)

• Apply warm compresses to the affected eyelid for 5-10 minutes, 3-4 times daily to soften crusts, warm meibomian secretions, and promote drainage 1
• Clean the eyelid margin using diluted baby shampoo or commercially available eyelid cleaner once or twice daily to remove debris and inflammatory material 1
• Perform gentle vertical massage of the eyelid to help express secretions, particularly for posterior blepharitis/meibomian gland involvement 1

Second-Line Management (For Worsening Hordeolum)

• Consider changing the topical antibiotic to mupirocin 2% ointment, which may be more effective against resistant organisms like MRSA that are increasingly common in community settings 2, 1
• Apply the antibiotic directly to the eyelid margins one or more times daily 1
• If the hordeolum shows signs of pointing (developing a "head"), incision and drainage should be performed to accelerate resolution 3

For Severe or Spreading Infection

• If there are signs of spreading infection (increasing redness, swelling beyond the immediate area, fever), oral antibiotics should be initiated 2
• For suspected MRSA infection, consider trimethoprim-sulfamethoxazole or tetracycline (doxycycline/minocycline), though treatment failure rates of up to 21% have been reported with tetracyclines 2
• Patients started on oral antibiotics should be reevaluated in 24-48 hours to verify clinical response 2

Special Considerations

• For pregnant women or children under 8 years, avoid tetracyclines and consider alternatives like erythromycin if oral antibiotics are needed 1
• In patients with advanced glaucoma, avoid aggressive manipulation of the eyelid as it may increase eye pressure 1
• If the hordeolum is recurrent or not responding to treatment after 2-4 weeks, consider referral to an ophthalmologist to rule out underlying conditions or atypical presentations 4

Important Clinical Pearls

• Cochrane reviews have found limited evidence for non-surgical interventions for acute internal hordeolum, highlighting the importance of proper drainage when conservative measures fail 5, 6
• A randomized controlled trial showed that combined antibiotic ophthalmic solution was not more effective than placebo after incision and curettage, suggesting that drainage itself is the key therapeutic intervention 3
• If the hordeolum persists despite appropriate treatment, consider the possibility of a misdiagnosis - the lesion could be a chalazion or, rarely, a malignant tumor requiring biopsy 4
• Patients should be advised that warm compress and eyelid cleansing treatment may need to be continued long-term, as symptoms often recur when treatment is discontinued 1

When to Refer to Ophthalmology

• If there is no improvement after incision and drainage plus appropriate antibiotic therapy 2
• If there are signs of orbital cellulitis or systemic illness 2
• For recurrent hordeola that suggest an underlying condition requiring specialized management 4
• If the lesion is atypical in appearance or behavior, to rule out malignancy 4