Stye (Hordeolum): Signs, Symptoms, Diagnosis, and Treatment
Clinical Presentation and Diagnosis
A stye (hordeolum) presents as a well-defined, painful, localized swelling at the eyelid margin, diagnosed clinically based on characteristic appearance without need for ancillary testing. 1, 2
Key Diagnostic Features:
- Acute onset of a tender, erythematous nodule at the eyelid margin 2
- Localized swelling with a well-defined mass, distinguishing it from diffuse eyelid swelling 2
- Pain and tenderness at the site of inflammation 1, 3
- May present with crusting at the base of eyelashes if associated with blepharitis 4, 5
- External hordeolum involves the glands of Zeis or Moll at the lash line 2, 6
- Internal hordeolum (hordeolum internum) involves the meibomian glands within the tarsal plate 7, 6
History to Elicit:
- Recurrent styes or chalazia suggest underlying chronic blepharitis or meibomian gland dysfunction 4, 6
- Duration of symptoms (acute vs. chronic presentation) 4
- Associated symptoms: redness, irritation, tearing, foreign body sensation 4, 3
- History of rosacea, atopic dermatitis, or seborrheic dermatitis 4
First-Line Treatment
Warm compresses applied for 5-10 minutes, 3-4 times daily, combined with gentle eyelid cleansing, constitute the cornerstone of initial management. 1, 7
Conservative Management Protocol:
- Warm compresses: Apply for 5-10 minutes, 3-4 times daily using water that is warm but not hot enough to burn the skin 1, 7
- Use hot tap water on a clean washcloth, over-the-counter heat packs, or homemade bean/rice bags heated in the microwave for sustained warmth 7
- Eyelid cleansing: Perform once or twice daily immediately after warm compresses using diluted baby shampoo or commercially available eyelid cleaner on a cotton ball, cotton swab, or clean fingertip 1, 7
- Eye cleaners containing hypochlorous acid at 0.01% have strong antimicrobial effects 7
- Gentle vertical massage of the eyelid helps express secretions from meibomian glands 1, 7
Critical Safety Warnings:
- Patients with neurotrophic corneas require proper counseling to avoid injury to corneal epithelium during eyelid cleaning 1, 7
- Patients with advanced glaucoma should avoid aggressive pressure on eyelids as it may increase intraocular pressure 1, 7
- Eyelid cleaning can be dangerous if the patient lacks manual dexterity 7
Second-Line Treatment (If No Improvement After 2-4 Weeks)
Topical antibiotic ointment such as bacitracin or erythromycin applied to the eyelid margins one or more times daily should be initiated if conservative measures fail. 1, 7
Topical Antibiotic Options:
- Bacitracin or erythromycin ointment applied to eyelid margins one or more times daily or at bedtime for a few weeks 1, 7
- Mupirocin 2% topical ointment is an alternative for minor skin infections 1, 7
- Frequency and duration should be guided by severity and response to treatment, with consideration of using different antibiotics intermittently to prevent resistant organisms 1
Oral Antibiotics: When and Which Ones
Oral antibiotics are reserved for persistent cases with meibomian gland dysfunction not controlled by topical treatments, or when there are signs of spreading infection. 1, 7
Indications for Oral Antibiotics:
- Worsening hordeolum despite conservative management with signs of spreading infection 1
- Moderate to severe meibomian gland dysfunction not adequately controlled by eyelid cleansing or topical treatments 1, 7
Antibiotic Selection:
- First choice: Doxycycline, minocycline, or tetracycline for adults (contraindicated in pregnancy and children under 8 years) 1, 7
- For suspected MRSA: Trimethoprim-sulfamethoxazole or tetracycline (doxycycline/minocycline), though treatment failure rates up to 21% have been reported with tetracyclines 1
- For pregnant women and children under 8: Erythromycin or azithromycin 1, 7
- Reevaluate in 24-48 hours to verify clinical response 1
Surgical Intervention
Incision and drainage is recommended for worsening hordeolum that fails conservative management. 1, 7
When to Perform Incision and Drainage:
- Worsening upper eyelid hordeolum despite warm compresses and topical treatment 1
- Persistent internal hordeolum not responding to 2-4 weeks of conservative management 7
- Combine with oral antibiotics if signs of spreading infection are present 1
Urgent Referral Indications
Immediate ophthalmology referral is mandatory for signs of orbital cellulitis, systemic illness, or failure of appropriate therapy. 1, 7
Red Flags Requiring Urgent Referral:
- Signs of orbital cellulitis: changes in extraocular movements, vision changes, ophthalmoplegia 2, 8
- Systemic illness or extensive infection 1
- No improvement after incision and drainage plus appropriate antibiotic therapy 1, 7
- Markedly asymmetric lesions, resistant to appropriate therapy, or recurrent in the same location (to exclude carcinoma) 7, 9
- Gradual enlargement, central ulceration, irregular borders, eyelid margin destruction, or loss of lashes 9
Long-Term Management and Prevention
Patients should be counseled that warm compress and eyelid cleansing may be required long-term, as symptoms often recur when treatment is discontinued. 1, 7
- Regular eyelid hygiene is essential for those prone to styes or with chronic blepharitis 7
- Follow-up should be based on severity and response to treatment 7
- Consider underlying conditions such as rosacea or seborrheic dermatitis that may predispose to recurrence 4, 6