Aetiology

Acute localised infection or inflammation of the sebaceous or apocrine
glands of the eyelid. There are two types:

• external hordeolum (stye) – acute bacterial infection of the lash follicle and its associated gland of Zeis or Moll
• internal hordeolum – acute bacterial infection of Meibomian gland

These infections are usually staphylococcal. Recurrences are common. An untreated internal hordeolum may develop into a chalazion or preseptal cellulitis (see Clinical Management Guidelines on Chalazion and Cellulitis (preseptal and orbital))

Predisposing factors

Individuals with poor eyelid hygiene, inflammatory diseases of the eyelid (e.g. blepharitis)

Symptoms of hordeolum

Tender lump in eyelid
Epiphora
Local redness of eye and lid

Signs of hordeolum

External hordeolum
Tender inflamed swelling of the lid margin. May point anteriorly through the skin
Occasionally, multiple abscesses involve entire eyelid

Internal hordeolum
Tender inflamed swelling within the tarsal plate. More painful than a stye.
May point anteriorly through the skin or posteriorly through the conjunctiva

Differential diagnosis

Preseptal cellulitis
Haematoma of eyelid
Acute dacryocystitis
Chalazion (blockage of Meibomian gland with cyst formation)
Sebaceous cell carcinoma

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

GRADE* level of evidence and strength of recommendation always relates to the statement(s) immediately above

Most resolve spontaneously or discharge, followed by resolution

In the case of external hordeola, it may help to remove the lash associated with the infected follicle

Traditional remedies such as hot spoon bathing and/or warm compresses (between 40-45°C for up to 10 mins) may relieve symptoms
(GRADE*: Level of evidence=low; Strength of recommendation=strong)

Manage associated blepharitis with lid hygiene (see Clinical Management Guideline on Blepharitis)
(GRADE*: Level of evidence = low; Strength of recommendation = strong)

Rarely, refer for incision in cases that do not discharge (commoner with internal hordeolum)

Advise patient to return/seek further help if symptoms persist

Consider course of antibiotic drops or ointment (e.g. chloramphenicol) in the presence of copious muco-purulent discharge
In severe or recurrent cases, consider management with systemic broad-spectrum antibiotic, e.g. an oral first generation cephalosporin or amoxicillin/clavulanic acid
(GRADE*: Level of evidence=low; Strength of recommendation=strong)
 

Management category

B2: alleviation/palliation: normally no referral

Possible management by ophthalmologist

Possible incision, but surgery rarely performed in presence of acute infection

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (see www.gradeworkinggroup.org)
 

Sources of evidence

Bilkhu PS, Naroo SA, Wolffsohn JS. Effect of a commercially available warm compress on eyelid temperature and tear film in healthy eyes. Optom Vis Sci. 2014;91(2):163-70.

Lindsley K, Nichols JJ, Dickersin K. Non-surgical interventions for acute internal hordeolum. Cochrane Database of Syst Rev. 2017;1:CD007742

Hordeolum
Version 13
Date of search 23.10.22
Date of revision 20.12.22
Date of publication 20.02.23
Date for review 22.10.24
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