What is the recommended treatment for a patient presenting with a stye?

Treatment of Stye (Hordeolum)

Start with warm compresses applied to the affected eyelid for 5-10 minutes, 3-4 times daily, combined with eyelid margin cleansing using diluted baby shampoo or commercial eyelid cleaners once or twice daily. 1

First-Line Conservative Management

The initial approach focuses on promoting natural drainage and removing inflammatory debris:

• Apply warm compresses for 5-10 minutes, 3-4 times daily to soften crusts, warm meibomian secretions, and facilitate spontaneous drainage 1
• Clean the eyelid margin using diluted baby shampoo or commercially available eyelid cleaner on a cotton ball, cotton swab, or clean fingertip once or twice daily to remove debris and inflammatory material 1
• Perform gentle vertical massage of the eyelid for posterior blepharitis or meibomian gland involvement to help express secretions 1
• Continue this regimen for 2-4 weeks before escalating treatment, as many hordeola resolve spontaneously with conservative measures alone 1

Important Caveats for Conservative Treatment

• Patients must understand that warm compress and eyelid cleansing may be required long-term, as symptoms frequently recur when treatment is discontinued 1
• Avoid aggressive eyelid manipulation in patients with advanced glaucoma, as this may increase intraocular pressure 1
• Patients with neurotrophic corneas require proper counseling to avoid corneal epithelial injury during eyelid cleaning 1

Second-Line Treatment: Topical Antibiotics

If no improvement occurs after 2-4 weeks of conservative management, add topical antibiotic ointment such as bacitracin or erythromycin applied to the eyelid margins one or more times daily. 1

• Bacitracin ophthalmic ointment should be applied directly into the conjunctival sac 1 to 3 times daily; for blepharitis, remove all scales and crusts first, then spread the ointment uniformly over the lid margins 2
• Erythromycin ophthalmic ointment is an alternative option, particularly for pregnant women or children under 8 years 1, 3
• Mupirocin 2% topical ointment can be considered as an alternative for minor skin infections and secondarily infected lesions 1
• The frequency and duration should be guided by severity and response, with consideration of using different antibiotics intermittently to prevent resistant organisms 1

Antibiotic Selection Considerations

• Avoid contaminating the ointment tip with material from the eye, fingers, or other sources 3
• Exercise caution when erythromycin is administered to nursing women 3
• Consider intermittent antibiotic rotation to prevent development of resistant organisms 1

Third-Line Treatment: Oral Antibiotics

For persistent or severe cases not responding to topical treatment, consider oral antibiotics such as doxycycline, minocycline, or tetracycline for patients with meibomian gland dysfunction. 1

• Doxycycline, minocycline, or tetracycline may be used for patients whose symptoms are not adequately controlled by eyelid cleansing or topical treatments 1
• These agents are contraindicated in pregnancy and children under 8 years 1
• Alternative oral antibiotics such as erythromycin or azithromycin should be used for women of childbearing age and children 1

Surgical Intervention: Incision and Drainage

For worsening upper eyelid hordeolum despite conservative and antibiotic management, proceed with incision and drainage. 1

• Incision and drainage is recommended as the next step for worsening hordeolum, along with continued warm compresses 1
• If signs of spreading infection are present, initiate oral antibiotics with consideration of trimethoprim-sulfamethoxazole or tetracycline (doxycycline/minocycline) for suspected MRSA infection 1
• Reevaluate patients started on oral antibiotics in 24-48 hours to verify clinical response 1

When to Refer to Ophthalmology

Immediate ophthalmology referral is necessary in the following situations:

• No improvement after incision and drainage plus appropriate antibiotic therapy 1
• Signs of orbital cellulitis or systemic illness 1
• Stye in an area difficult to treat, such as the inner eyelid 1
• Signs of systemic illness or extensive infection 1

Role of Topical Corticosteroids

• Topical corticosteroids may provide symptomatic relief but should be used with caution and only under ophthalmological supervision 1
• In patients with advanced glaucoma, use steroid-containing drops with extreme caution and monitor intraocular pressure closely 1
• Baseline and periodic measurement of IOP and pupillary dilation should be performed when corticosteroids are used to evaluate for glaucoma and cataract 4

Special Population Considerations

• Pregnant women and children under 8 years: Avoid tetracyclines; use erythromycin if oral antibiotics are needed 1
• Patients with advanced glaucoma: Avoid aggressive eyelid manipulation and use steroids with caution 1
• Neurotrophic cornea patients: Provide proper counseling to prevent corneal epithelial injury during cleaning 1