Hordeolum (Stye): Diagnosis, Management & Referral Guidelines

✅ 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

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📊 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
  

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🧠 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

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⏱️ 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

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🧾 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

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⚠️ 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
  

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📌 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