Treatment of Internal Hordeolum
The treatment of internal hordeolum consists primarily of warm compresses, eyelid hygiene with massage to express meibomian glands, and topical antibiotics, though high-quality evidence supporting specific interventions is lacking. 1
Initial Conservative Management (First-Line)
The cornerstone of treatment involves supportive measures that most practitioners implement before considering surgical intervention:
- Warm compresses applied to the affected eyelid help promote spontaneous drainage and resolution 1
- Eyelid cleansing and massage to express the meibomian glands, particularly important since internal hordeola affect these glands 1
- Artificial tears may provide symptomatic relief for associated ocular surface irritation 1
Most practitioners pursue conservative management for 5 to 14 days before considering surgical intervention 2
Topical Antibiotic Therapy
While evidence is limited, topical antibiotics are widely used in clinical practice:
- Topical antibiotics are preferred by approximately 74% of practitioners for treating hordeolum, with 84% considering them effective 2
- Azithromycin hydrate ophthalmic solution (twice daily for 2 days, then once daily for 12 days) has shown efficacy in treating internal hordeolum, with complete resolution of inflammatory findings in small case series 3
- This is particularly relevant since Cutibacterium acnes has been cultured from meibomian gland secretions in patients with inflammatory meibomian gland disease 3
Important caveat: Cochrane systematic reviews found no randomized controlled trials evaluating non-surgical interventions for acute internal hordeolum, meaning current practice is based on clinical experience rather than high-quality evidence 4, 5
When to Consider Surgical Intervention
Incision and curettage should be considered when:
- Conservative management fails after 5-14 days 2
- The lesion does not drain spontaneously 4, 5
- Symptoms worsen or spread to adjacent tissues 1
- The acute internal hordeolum becomes chronic or develops into a chalazion 4, 5
Special Considerations and Red Flags
Biopsy is indicated in cases of:
- Marked asymmetry or resistance to therapy 1
- Unifocal recurrent lesions that do not respond well to treatment 1
- Loss of normal eyelid margin anatomy, conjunctival changes, or focal lash loss (ciliary madarosis), which may suggest sebaceous carcinoma 1
In children, chronic blepharokeratoconjunctivitis with recurrent hordeola is often unrecognized and can be more severe, potentially leading to corneal opacification and amblyopia 1
Evidence Limitations
The lack of controlled trials means we cannot definitively state which interventions are most effective 4, 5. Current practice patterns reflect clinical consensus rather than evidence-based protocols. The natural history of internal hordeolum includes spontaneous drainage and resolution in many cases within approximately one week 4, 5, 6, making it difficult to attribute improvement to any specific intervention without controlled studies.