What eye ointments can be prescribed for a patient with a hordeolum (sty) and no known allergies?

Treatment of Hordeolum (Sty) with Eye Ointments

For a patient with hordeolum and no allergies, warm compresses and lid hygiene are the primary treatment, as there is no high-quality evidence supporting the use of any specific eye ointment for acute hordeolum. 1, 2

Evidence-Based Treatment Approach

First-Line Conservative Management

• Warm compresses applied to the closed eyelid using specially designed battery-powered or microwaveable devices (not hot water-soaked flannels due to scalding risk) should be used, followed by eyelid massage and lid margin cleaning 3
• Lid hygiene measures using commercially available lid wipes or homemade bicarbonate solution to clean eyelid margins, unblock oil glands, and remove excess bacteria 3
• This conservative approach can be trialed for up to 3 months but should be discontinued if eye symptoms worsen 3

Critical Evidence Gap

• No randomized controlled trials exist evaluating any non-surgical interventions (including antibiotics, steroids, or other ointments) for acute internal hordeolum 1, 2
• Most hordeola drain spontaneously and resolve without treatment within approximately one week 1, 2

Antibiotic Ointments: Limited Role

• Topical antibiotic ointments (such as bacitracin) are NOT indicated for uncomplicated hordeolum, as the condition is typically self-limited and antibiotics have not been proven effective 1, 2
• Bacitracin ointment is labeled for external use only and specifically warns against use "in the eyes" 4
• Indiscriminate use of topical antibiotics should be avoided as they can induce ocular surface toxicity and contribute to antibiotic resistance 5

When Ointments Might Be Considered (Off-Label)

• If secondary bacterial infection or blepharitis is suspected (increased crusting, weeping, or pustules), oral antibiotics (flucloxacillin or erythromycin if penicillin-allergic) are preferred over topical ointments 6
• For associated eyelid eczema or chronic blepharitis, tacrolimus 0.1% ointment applied once daily to external eyelids and lid margins may be beneficial, though this is off-label for hordeolum 3

Important Clinical Pitfalls

What NOT to Prescribe

• Avoid topical corticosteroid ointments for simple hordeolum, as they are not indicated and carry risks of increased intraocular pressure, cataract formation, and secondary infections 3, 5
• Avoid antihistamine or mast cell stabilizer eye drops/ointments, as hordeolum is an infectious/inflammatory process, not an allergic condition 3, 5
• Do not use triple antibiotic ointments (bacitracin/neomycin/polymyxin B) in or around the eyes without clear indication, as they are labeled for external use only 4

Monitoring and Referral

• Most hordeola resolve spontaneously within 7 days 1, 2
• If the hordeolum persists beyond 1-2 weeks, becomes chronic, or develops into a chalazion, referral to ophthalmology for possible incision and drainage may be necessary 1, 2
• Watch for spread of infection to adjacent glands or development of generalized eyelid cellulitis, which would require systemic antibiotics 1, 2

Key Takeaway

The absence of evidence for any specific ointment treatment means that conservative management with warm compresses and lid hygiene remains the standard of care for acute hordeolum. 1, 2 The condition's self-limited nature makes aggressive pharmacological intervention unnecessary in most cases.