The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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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)


Tender lump in eyelid
Local redness of eye and lid


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

Non pharmacological

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, wet or dry,  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
(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

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

Plain language summary

A hordeolum is an acute bacterial infection of the glands of the eyelid. An internal hordeolum affects the Meibomian (oil) glands within the eyelids whereas an external hordeolum (stye) affects the glands associated with the eyelashes. Both conditions cause red and tender swellings of the eyelid. Traditional remedies such as hot spoon bathing and/or warm compresses may relieve symptoms. In some cases, treatment with antibiotic drops or ointment is needed to speed up resolution. If there is a severe infection, antibiotic tablets may be prescribed.

Version 12
Date of search 27.07.20
Date of revision 31.07.20
Date of publication 06.08.21
Date for review 26.07.22
© College of Optometrists 

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