Treatment of Eye Stye (Hordeolum)
Start with warm compresses applied to the affected eyelid for 5-10 minutes, 3-4 times daily, combined with daily eyelid margin cleansing using diluted baby shampoo or commercial eyelid cleaners. 1, 2
First-Line Conservative Management
The initial approach focuses on promoting natural drainage without antibiotics:
- Apply warm compresses for 5-10 minutes, 3-4 times daily to soften crusts, warm meibomian secretions, and facilitate drainage of the infected gland 1, 2
- Perform gentle eyelid massage following warm compresses to help express the blocked gland contents 2
- Clean the eyelid margin once or twice daily using diluted baby shampoo or commercially available eyelid cleaners on a cotton ball, cotton swab, or clean fingertip to remove debris and inflammatory material 1, 2
- For posterior involvement, perform gentle vertical massage of the eyelid to help express meibomian gland secretions 1
- Avoid wearing contact lenses during the entire treatment period 2
This conservative approach should be continued for 2-4 weeks before escalating therapy. 1
Second-Line Topical Antibiotic Treatment
If no improvement occurs after 2-4 weeks of conservative management, apply topical antibiotic ointment such as bacitracin or erythromycin to the eyelid margins (not into the conjunctival sac) one or more times daily for a few weeks. 1, 3
- Apply approximately 1 cm ribbon of erythromycin or bacitracin ointment directly to the eyelid margins where lashes emerge, 1-2 times daily for 7-10 days 2, 3
- Adjust frequency based on severity: mild cases once daily at bedtime, more severe cases up to 4-6 times daily 3
- Rotate different antibiotics intermittently to prevent development of resistant organisms 1, 3
- Mupirocin 2% topical ointment is an alternative option for minor skin infections 1
Third-Line Oral Antibiotic Treatment
For persistent cases not responding to topical treatment after several weeks:
- Oral doxycycline, minocycline, or tetracycline may be considered for patients with meibomian gland dysfunction whose symptoms are not adequately controlled by topical treatments 1
- For pregnant women or children under 8 years, use erythromycin or azithromycin instead, as tetracyclines are contraindicated 1, 4
- Pediatric oral erythromycin dosing: 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks 3
Surgical Intervention
For worsening hordeolum despite medical management, incision and drainage is the next step, with consideration of oral antibiotics if signs of spreading infection develop. 1
- Consider trimethoprim-sulfamethoxazole or tetracycline (doxycycline/minocycline) for suspected MRSA infection, though treatment failure rates up to 21% have been reported with tetracyclines 1
- Reevaluate patients started on oral antibiotics in 24-48 hours to verify clinical response 1
When to Refer to Ophthalmology
- Immediate referral if signs of orbital cellulitis or systemic illness develop 1
- Refer if no improvement after incision and drainage plus appropriate antibiotic therapy 1
- Consider evaluation for underlying conditions like blepharitis or meibomian gland dysfunction if multiple recurrences occur 2
- Refer if the stye is in a difficult location such as the inner eyelid 1
Critical Pitfalls to Avoid
- Do not delay warm compress treatment—it should be started immediately upon diagnosis 2
- Do not apply erythromycin ointment into the conjunctival sac when treating blepharitis/hordeolum; the target is the eyelid margin where bacterial colonization occurs 3
- Avoid overusing topical antibiotics when conservative management alone would suffice 2
- Avoid aggressive eyelid manipulation in patients with advanced glaucoma, as it may increase intraocular pressure 1
- Counsel patients with neurotrophic corneas to avoid injury to corneal epithelium during eyelid cleaning 1