What is the initial management of a stye (hordeolum) in the emergency department (ED)?

Management of Stye (Hordeolum) in the Emergency Department

The initial management of a stye (hordeolum) in the emergency department should focus on warm compresses applied to the affected area 3-4 times daily, along with gentle lid hygiene, and consideration of topical antibiotic ointment for more severe cases. 1, 2

Initial Assessment and Diagnosis

• A stye (hordeolum) is a common, painful inflammation of the eyelid margin usually caused by bacterial infection affecting the oil glands of the eyelid 1
• Internal hordeolum affects the meibomian glands within the eyelid, while external hordeolum (commonly called a stye) affects glands at the eyelid margin 2
• Clinical presentation typically includes localized eyelid swelling, redness, pain, and sometimes a visible "point" where pus is collecting 1

First-Line Treatment

• Warm compresses are the cornerstone of treatment and should be applied to the affected area for 10-15 minutes, 3-4 times daily 1, 2

  • The warm compress increases blood circulation to the area, which helps the body fight infection and promotes drainage
  • Patient should be instructed to use clean, warm (not hot) washcloths for this purpose

• Lid hygiene should be performed daily using gentle cleansing of the eyelid margins 1

  • This helps remove debris and bacteria that may contribute to the infection
  • Can be done with diluted baby shampoo or commercial eyelid cleansers

Medication Management

• Topical antibiotic ointments may be considered for more severe cases or when there are signs of spreading infection 3

  • Bacitracin can be applied to the affected area 1-3 times daily 3
  • A small amount (equal to the surface area of the tip of a finger) should be applied directly to the affected area

• Systemic antibiotics are generally not indicated for uncomplicated hordeola 1, 2

  • Reserve oral antibiotics for cases with significant surrounding cellulitis, systemic symptoms, or immunocompromised patients 4

Patient Education and Follow-up

• Advise patients that most hordeola will resolve spontaneously within 1-2 weeks with conservative treatment 1

• Instruct patients to avoid:

  • Squeezing or attempting to "pop" the stye 1
  • Wearing contact lenses until the condition resolves 2
  • Sharing towels or washcloths to prevent spread of infection 4

• Recommend follow-up with an ophthalmologist if:

  • Symptoms worsen despite 48-72 hours of treatment 1
  • Vision becomes affected 2
  • The hordeolum persists beyond 2 weeks (may be developing into a chalazion) 1
  • There is recurrence of hordeola (may indicate need for more aggressive management) 2

Special Considerations

• For children under 2 years of age, consult with an ophthalmologist before initiating treatment 3
• Patients with diabetes or immunocompromised status may require closer monitoring and earlier referral to ophthalmology 4
• Recurrent hordeola may indicate underlying conditions such as blepharitis, rosacea, or seborrheic dermatitis that require additional treatment 2

Common Pitfalls to Avoid

• Misdiagnosing more serious conditions (preseptal/orbital cellulitis, malignancy) as simple hordeola 4
• Unnecessary use of systemic antibiotics for uncomplicated cases 5, 4
• Premature incision and drainage in the ED setting (generally not indicated unless there is a well-formed pointing abscess) 1, 2
• Failure to recognize when a hordeolum has evolved into a chalazion, which may require different management 1