Hordeolum (Stye): Diagnosis, Management & Referral Guidelines
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✅ Diagnosis Criteria
A clinical diagnosis based on history and physical examination.
🔍 Diagnostic Features:
| Feature | Description |
| Onset | Acute (hours to 1–2 days) |
| Location | Eyelid margin (external) or deeper in lid (internal) |
| Pain | Present (distinguishes from chalazion) |
| Tenderness | Localized; palpable nodule |
| Swelling | Focal edema of eyelid (may progress to diffuse swelling) |
| Erythema | Present, often localized to lesion |
| Discharge | May occur, especially in external hordeolum (purulent) |
| Systemic signs | Rare; consider if preseptal cellulitis develops |
📊 Types:
- External Hordeolum: Infected gland of Zeis or Moll (eyelash follicle), visible on lid margin
- Internal Hordeolum: Infected Meibomian gland, deeper and often not visible on surface
🧠 Differential Diagnosis
| Condition | Key Differences |
| Chalazion | Chronic, painless, noninfectious; granulomatous |
| Preseptal cellulitis | Diffuse eyelid swelling, +/- fever, no focal nodule |
| Dacryocystitis | Infection of lacrimal sac, often medial lower eyelid |
| Sebaceous carcinoma | Suspect in nonresolving, recurrent nodules in elderly |
⏱️ Follow-up & Ophthalmology Referral
🗓️ Routine Follow-up:
- Mild cases: 1–2 weeks (expect resolution or spontaneous drainage)
- Reevaluate if not improving in 7–10 days
👁️ Refer to Ophthalmology if:
- Internal hordeolum not responding to warm compress + topical abx in 1–2 weeks
- Signs of preseptal or orbital cellulitis:
- Diffuse swelling
- Fever
- Impaired eye movement
- Proptosis
- Recurrent hordeolum (may need biopsy to rule out malignancy)
- Suspected chalazion requiring I&D
🧾 Management
🩹 First-line (Conservative/Supportive):
- Warm compresses:
- 10–15 min, 3–5 times/day
- Softens lesion, promotes drainage
- Gentle massage: after warm compress to assist drainage
💊 Topical Antibiotics (if infection suspected or recurrent):
- Erythromycin ophthalmic ointment 0.5%
- Apply 2–4× daily for 7–10 days
- Alternative: Bacitracin ointment
Not necessary in all uncomplicated cases; reserve for purulence, blepharitis, or conjunctivitis.
💊 Oral Antibiotics (only for complicated cases):
Indications:
- Internal hordeolum with diffuse swelling
- Suspected preseptal cellulitis
- Multiple lesions or immunocompromised patients
| Drug | Dose |
| Cephalexin | 500 mg PO every 6 hours for 7 days |
| Dicloxacillin | 250–500 mg PO qid for 7 days |
| MRSA risk | Clindamycin or TMP-SMX |
🛠️ Surgical Management:
- Indicated if:
- No response in >1–2 weeks
- No drainage
- Severe internal hordeolum
- Patient discomfort
- Incision & drainage (I&D) by ophthalmologist under sterile conditions
⚠️ Prevention & Patient Education
- Do not squeeze the lesion
- Avoid contact lenses & eye makeup during infection
- Eyelid hygiene:
- Lid scrubs
- Avoid eye rubbing
- Discard contaminated cosmetic products
📌 Summary Table
| Treatment | Indication |
| Warm compresses | First-line for all cases |
| Topical antibiotics | Recurrent, purulent, or blepharitis |
| Oral antibiotics | Internal, cellulitis, immunocomp. |
| Surgical drainage | Non-resolving or large internal lesion |
| Refer ophthalmology | Persistent 2 wk, recurrent, or complicated |
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