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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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

Predisposing factors

Chronic blepharitis


  • Tender lump in eyelid
  • Epiphora
  • 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

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

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 may relieve symptoms
  • Manage associated blepharitis with lid hygiene (see Clinical Management Guideline on Blepharitis)
  • Rarely, refer for incision in cases that do not discharge (commoner with internal hordeolum)
  • An internal hordeolum may evolve into a chalazion (see Clinical Management Guideline on Chalazion)
  • Advise patient to return/seek further help if symptoms persist

(GRADE*: Level of evidence=low; Strength of recommendation=strong)


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 antibiotics (possible co-management with GP)

(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
  • See also Clinical Management Guidelines on Chalazion, Pre-septal Cellulitis

Evidence base

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

Sources of evidence

Lindsley K, Nichols JJ, Dickersin K. Interventions for acute internal hordeolum. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD007742. DOI: 10.1002/14651858.CD007742.pub3

Lay 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 (commonly referred to as a 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. In the case of a severe infection, antibiotic tablets may be required.

Version 9
Date of search 13.09.14
Date of revision 16.12.14
Date of publication 16.02.15
Date for review 12.09.16
© College of Optometrists 

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