Hordeolum

Hordeolum (stye) is an acute, localised, painful bacterial infection of the glands of the eyelid, most often Staphylococcus aureus.

• External hordeolum: infection of the glands of Zeis or Moll at the lid margin, pointing to the skin at a lash base.
• Internal hordeolum: acute infection of a meibomian gland within the tarsal plate, pointing toward the conjunctiva; it can be more painful and may progress to a chalazion.
• Associated conditions: blepharitis, diabetes, immunosuppression, rosacea, and poor lid hygiene.

• Rapid onset of localised, tender, red, swollen lump on the lid margin or within the lid, with pain, warmth, tearing, and sometimes a yellow pustule at the lash margin.
• Eyelid oedema may be marked and extend to the cheek; low grade fever is uncommon.
• Resolution through spontaneous drainage within 1 to 2 weeks.
• Signs of complication: diffuse lid swelling with erythema and fever (preseptal cellulitis), pain with eye movement, proptosis, or reduced vision (orbital extension).

• Clinical, with eversion of the lid to look for an internal hordeolum and exclusion of diffuse cellulitis.
• Swab culture is reserved for recurrent, severe, or treatment resistant disease and for suspected methicillin resistant Staphylococcus aureus.
• Examine for blepharitis; check glucose in recurrent cases.
• Recurrent or atypical lesions in older patients should be biopsied for sebaceous gland carcinoma.

• Warm compresses for 10 to 15 minutes four to six times daily, with gentle massage to promote drainage; lid hygiene; do not squeeze.
• Epilation of the lash at the point of an external hordeolum can promote drainage.
• Topical antibiotic ointment (erythromycin 0.5 percent, fusidic acid 1 percent, or chloramphenicol 1 percent) to the lid margin twice to three times daily for 5 to 7 days is commonly used, though evidence of benefit is limited.
• Oral antibiotics are indicated for spreading cellulitis, multiple lesions, fever, immunocompromised patients, or lesions not improving within 48 to 72 hours: flucloxacillin 500 mg every 6 hours for 5 to 7 days (child 12.5 to 25 mg/kg every 6 hours) or cefalexin 500 mg every 8 hours; for penicillin allergy or suspected MRSA, clindamycin 300 mg to 450 mg every 6 to 8 hours, or doxycycline 100 mg twice daily (adults), or trimethoprim-sulfamethoxazole 160 mg/800 mg twice daily.
• Analgesia: paracetamol 1 g every 6 hours, ibuprofen 400 mg every 8 hours.
• Incision and drainage for a pointing or fluctuant abscess that fails to settle after 48 to 72 hours of compresses: external lesions via a small horizontal skin incision, internal lesions through a vertical conjunctival incision, under local anaesthesia, with swab for culture.
• Treat predisposing blepharitis, rosacea, and diabetes; counsel hand hygiene and lid hygiene to prevent recurrence; avoid eye make up and contact lenses until healed.
• Complications: chalazion, preseptal and orbital cellulitis, lid scarring and notching, and recurrence.