HORDEOLUM (STYE)

Konstantinos E. Deligiannidis, MD, MPH, FAAFP

 BASICS

DESCRIPTION

•  An acute inflammation or infection of the eyelid margin involving the sebaceous gland of an eyelash (external hordeolum) or a meibomian gland (internal hordeolum)

•  System(s) affected: skin/exocrine

•  Synonym(s): internal hordeolum; external hordeolum; Zeisian stye; meibomian stye; stye

EPIDEMIOLOGY

•  Predominant age: none

•  Predominant sex: male = female

Incidence

Unknown: Although external hordeolum is common, internal hordeolum is rare.

ETIOLOGY AND PATHOPHYSIOLOGY

•  Bacterial infection of sebaceous or meibomian glands, causing an acute inflammatory reaction

•  In an internal hordeolum, the meibomian gland may become obstructed, leading to a pustule on the conjunctival surface as opposed to the margin of the eyelid.

•  Most commonly caused by Staphylococcus aureus (~90–95% of all cases) or by Staphylococcus epidermidis

•  Seborrhea can predispose to infections of the eyelid.

Genetics

No known genetic pattern

RISK FACTORS

•  Poor eyelid hygiene

•  Previous hordeolum

•  Contact lens wearers

•  Application of makeup

•  Predisposing blepharitis (low-grade infections of the eyelid margin)

•  Ocular rosacea

GENERAL PREVENTION

Eyelid hygiene

COMMONLY ASSOCIATED CONDITIONS

•  Acne

•  Seborrhea

•  An association may exist between hordeolum during childhood and developing rosacea in adulthood.

 DIAGNOSIS

HISTORY

•  Localized inflammation (vs. involvement of the entire eyelid or surrounding skin)

•  Foreign body sensation in the eye

•  Prior episodes are common.

PHYSICAL EXAM

•  Localized inflammation of the eyelashes or a small pustule at the margin of the eyelid

•  Localized swelling and tenderness on the internal or external aspect of the eyelid with an opening to either side

•  To determine if an internal hordeolum is obstructed, the eyelid should be gently everted to examine for a pustule on the tarsal conjunctiva.

•  Itching or scaling of the eyelids; collection of discharge, redness, and irritation leading to localized tenderness and pain

•  The size of the swelling usually correlates to the severity of the hordeolum.

DIFFERENTIAL DIAGNOSIS

•  Chalazion

•  Blepharitis

•  Eyelid neoplasms

•  Periorbital cellulitis

•  Dacryocystitis

DIAGNOSTIC TESTS & INTERPRETATION

Culture of the eyelid margins usually is not necessary.

Diagnostic Procedures/Other

History and eye exam

Test Interpretation

Bacterial contamination and white cells in eyelid discharge

 TREATMENT

GENERAL MEASURES

•  The hordeolum should not be expressed.

•  Warm compresses to the area of inflammation can help increase blood supply and encourage spontaneous drainage.

•  Good personal hygiene with attention to cleansing the eyelids on a daily basis helps to prevent recurrent infections.

MEDICATION

First Line

•  A Cochrane review found no evidence for or against nonsurgical treatment of internal hordeolum. External hordeola were not considered (1)[A].

•  Usually, a hordeolum spontaneously drains, aided by warm compresses to the area.

•  Also, lid scrubs, digital massage, and alternative medicine have been used to reduce healing time and relieving symptoms.

•  Application of an antibiotic ointment (e.g., erythromycin) to the margin of the eyelid after proper cleansing (except in children age <12 years, in whom there is a risk of blurred vision and amblyopia) helps reduce bacterial proliferation. There is little evidence that any topical therapy is effective. Erythromycin ophthalmic ointment may be applied up to 6 times per day for 7 to 10 days or an antibiotic ointment containing bacitracin (2,3)[C].

•  Treat underlying dry eye with artificial tears.

Second Line

•  Occasionally, the use of an aminoglycoside ophthalmic ointment, such as gentamicin or tobramycin, may be necessary if condition is refractory to simpler treatment (case reports).

•  Oral dicloxacillin or cephalexin for 2 weeks if refractory to topical antibiotics

ISSUES FOR REFERRAL

Consider referral if unresponsive to oral antibiotics.

SURGERY/OTHER PROCEDURES

•  If the infection becomes localized to a single gland, incision, drainage, or curettage sometimes is necessary. This is an in-office procedure with a local anesthetic: Exercise caution because ocular perforation has been reported with the injection of an anesthetic to an infected lid.

•  Use of combined antibiotic ointment (neomycin sulfate, polymyxin B sulfate, and gramicidin) after surgery was not shown to have any statistically significant benefit compared with artificial tears.

COMPLEMENTARY & ALTERNATIVE MEDICINE

Broncasma berna is a polyvalent antigen vaccine that may be useful in the treatment of recurrent hordeolum.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Outpatient

 ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

No restrictions

Patient Monitoring

The patient should be seen within several weeks to assess the effectiveness of therapy or should at least call the physician’s office with a progress report.

DIET

No special diet

PATIENT EDUCATION

•  The patient should be instructed in proper cleansing of the eyelids using a solution of tap water and baby shampoo or a commercially prepared hypoallergenic cleanser.

•  The stye should not be squeezed or incised.

PROGNOSIS

•  Usually responds well to good hygiene and warm compresses

•  Inflammation usually improves within a week.

•  Hordeolum tends to recur in some patients, usually due to incomplete elimination of bacteria.

COMPLICATIONS

An internal hordeolum, if untreated, may lead to chalazion, infections of adjacent glands, or generalized cellulitis of the lid.

REFERENCES

1.  Lindsley K, Nichols JJ, Dickersin K. Interventions for acute internal hordeolum. Cochrane Database Syst Rev. 2013;(4):CD007742.

2.  Wald ER. Periorbital and orbital infections. Pediatr Rev. 2004;25(9):312–320.

3.  Mueller JB, McStay CM. Ocular infection and inflammation. Emerg Med Clin North Am. 2008;26(1):57–72.

ADDITIONAL READING

•  Bamford JT, Gessert CE, Renier CM, et al. Childhood stye and adult rosacea. J Am Acad Dermatol. 2006;55(6):951–955.

•  Hirunwiwatkul P, Wachirasereechai K. Effectiveness of combined antibiotic ophthalmic solution in the treatment of hordeolum after incision and curettage: a randomized, placebo-controlled trial: a pilot study. J Med Assoc Thai. 2005;88(5):647–650.

•  Kim JH, Yang SM, Kim HM, et al. Inadvertent ocular perforation during lid anesthesia for hordeolum removal. Korean J Ophthalmol. 2006;20(3):199–200.

•  Nakatani M. Treatment of recurrent hordeolum with Broncasma Berna. Eye (Lond). 1999;13(Pt 5):692.

•  Wald ER. Periorbital and orbital infections. Infect Dis Clin North Am. 2007;21(2):393–408, vi.

 CODES

ICD10

•  H00.019 Hordeolum externum unspecified eye, unspecified eyelid

•  H00.029 Hordeolum internum unspecified eye, unspecified eyelid

•  H00.039 Abscess of eyelid unspecified eye, unspecified eyelid

CLINICAL PEARLS

•  A hordeolum should not be expressed.

•  Warm compresses to the area of inflammation can encourage spontaneous drainage.

•  Application of an antibiotic ointment (e.g., erythromycin) to the margin of the eyelid after proper cleansing helps reduce bacterial proliferation but may have no effect on the healing of the stye.

•  Good personal hygiene with attention to cleansing the eyelids on a daily basis can prevent recurrent infections.