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
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 resolutionIn 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
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)
An internal hordeolum may evolve into a chalazion (see Clinical Management Guideline on Chalazion)
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
See also Clinical Management Guidelines on Chalazion (Meibomian cyst), 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. 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 (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 recovery. In the case of a severe infection, antibiotic tablets may be required.

Version 11
Date of search 17.07.18
Date of revision 20.07.18
Date of publication 20.12.18
Date for review 16.07.20
© College of Optometrists 

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