eMedicine Specialties > Ophthalmology > Lid
Hordeolum
Updated: May 21, 2009
Introduction
Background
A hordeolum is a common disorder of the eyelid. It is an acute focal infection (usually staphylococcal) involving either the glands of Zeis (external hordeola, or styes) or, less frequently, the meibomian glands (internal hordeola).
Pathophysiology
There is usually underlying meibomitis with thickening and stasis of gland secretions with resultant inspissation of the Zeis or meibomian gland orifices. Stasis of the secretions leads to secondary infection, usually by Staphylococcus aureus. Histologically, hordeola represent focal collections of polymorphonuclear leukocytes and necrotic debris (ie, an abscess).
Hordeola should not be confused with chalazia, which represent focal, chronic, lipogranulomatous inflammation of the Zeis or meibomian glands. Chalazia form when underlying meibomitis results in stasis of gland secretions, and the contents of the glands (sebum) are released into the tarsus and adjacent tissues to incite a noninfectious inflammatory reaction. Histologically, chalazia appear as a granulomatous reaction (ie, histiocytes, multinucleated giant cells) surrounding clear spaces that were once occupied by sebum/lipid before they were dissolved by the solvents used for tissue processing, hence the term lipogranuloma.
Essentially, a hordeolum represents an acute focal infectious process, while a chalazion represents a chronic, noninfectious granulomatous reaction. However, chalazia often evolve from internal hordeola.
Frequency
United States
Hordeola are common in clinical practice, but no data are available on the precise incidence and prevalence in the United States.
International
No data are available on the incidence and prevalence of hordeola internationally. However, hordeola are among the most common eyelid lesions in clinical practice.
Race
There is no known racial predilection to developing hordeola.
Sex
There is no sexual predilection to developing hordeola. Both men and women seem to be equally affected.
Age
Hordeola are more common in adults than in children, possibly because of a combination of higher androgenic levels (and increased viscosity of sebum), higher incidence of meibomitis, and rosacea in adults. However, hordeola can occur in children.
Clinical
History
- Hordeola essentially represent focal abscesses; therefore, they will present with features of acute inflammation, such as a painful, warm, swollen, red lump on the eyelid.
- The eyelid lump may also induce corneal astigmatism and cause blurring of vision.
- The patient often has a past history of similar eyelid lesions or risk factors for hordeola, such as meibomian gland dysfunction, blepharitis, or rosacea.
- Clinically differentiating hordeola from acute chalazia may be difficult, because they both present with acute inflammation and tender eyelid lumps. However, chronic chalazia represent a granulomatous reaction and, thus, appear firm and nontender on clinical examination.
Physical
On examination, a tender erythematous subcutaneous nodule is present near the eyelid margin, which may undergo spontaneous rupture and drainage. If sufficient edema is present, then it may be difficult to palpate a discrete nodule. These nodules may be unilateral or bilateral, single or multiple.
The inflammation associated with hordeola may spread to adjacent tissue and cause a secondary preseptal cellulitis.
Patients may also have signs of meibomitis, blepharitis, or ocular rosacea.
Causes
Hordeola are associated with S aureus infection.
Patients with chronic blepharitis, meibomian gland dysfunction, and ocular rosacea are at greater risk of developing hordeola than the general population.
There are published case reports where multiple recurrent hordeola have been associated with selective immunoglobulin M (IgM) deficiency.
The lipid component of chalazia has been found to have large cholesterol content and is dissimilar to the lipid found in meibomian glands. Studies have reported an association between multiple chalazia and elevated serum cholesterol levels. Some studies have even suggested that elevated serum lipid levels may increase the risk of blockage to oil glands of the eyelids and, therefore, predispose to hordeola and chalazia.
Differential Diagnoses
Basal Cell Carcinoma, Eyelid
Cellulitis, Preseptal
Chalazion
Sebaceous Gland Carcinoma
Squamous Cell Carcinoma, Eyelid
Workup
Laboratory Studies
- The diagnosis is based on history and clinical examination, and cultures are not indicated in uncomplicated cases.
- There is no indication to check serum lipid levels, as the association among hordeola, chalazia, and hypercholesterolemia remains unclear.
Histologic Findings
Histopathology of a hordeolum reveals an abscess or a focal collection of polymorphonuclear leukocytes and necrotic tissue.
Histologically, chalazia represent a lipogranulomatous inflammatory reaction. Histiocytes, multinucleated giant cells, lymphocytes, plasma cells, and neutrophils surround an optically clear space. This optically clear space represents lipids that were dissolved by solvents during tissue processing.
Basal cell carcinoma or sebaceous cell carcinoma of the eyelid can be misdiagnosed clinically as a recurrent hordeolum or chalazion; therefore, histopathologic examination is very important in determining the diagnosis, especially in patients with a persistent or recurrent lesion.
Treatment
Medical Care
Hordeola are usually self-limited, spontaneously improving in 1-2 weeks.
Medical therapy for hordeola includes eyelid hygiene, warm compresses and massages of the lesions for 10 minutes 4 times per day, and topical antibiotic ointment in the inferior fornix if the lesion is draining or if there is an accompanying blepharoconjunctivitis.
Systemic antibiotics may be indicated if the hordeola is complicated by preseptal cellulitis. Oral doxycycline may also be added if there is a history of multiple or recurrent lesions or if there is significant and chronic meibomitis.
Internal hordeola may occasionally evolve into chalazia, which may require topical steroids, intralesional steroids, or surgical incision and curettage.
Surgical Care
Incision and drainage is indicated if the hordeolum is large or if it is refractory to medical therapy.
Incision and drainage is done under local anesthesia, and the incision is made through the skin and orbicularis (in the case of external hordeola) or through the tarsal conjunctiva and tarsus (in the case of internal hordeola). The specimen should be sent for histopathological evaluation to confirm the diagnosis and to rule out a more sinister pathology (eg, basal cell carcinoma).
Medication
The goals of pharmacotherapy are to treat the infection, to reduce morbidity, and to prevent complications.
Antibiotics
A course of oral antibiotics is indicated if the hordeolum is complicated by preseptal cellulitis.
Cephalexin (Keflex, Biocef, Keftab)
First-generation cephalosporin often used in skin or skin structure infections (eg, acute hordeolum) caused by staphylococci or streptococci. Administered orally and has a half-life of 50-80 min. Only 10% is protein bound and greater than 90% recovered unchanged in urine.
Dosing
Adult
250 mg PO qid or 500 mg PO bid for 7-10 d
Pediatric
20 mg/kg/d PO divided q8h for 7-10 d; in more serious infections, may increase dose to 40 mg/kg/d; not to exceed 1 g/d
Interactions
Coadministration with aminoglycosides increase nephrotoxic potential
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Erythromycin (E-Mycin)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Indicated for infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections.
Dosing
Adult
Apply 0.5-inch (1.25-cm) ribbon to affected eye 3 times/d
Pediatric
Apply as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity; viral, mycobacterial, and fungal infections of eye; patients using steroid combinations after uncomplicated removal of a foreign body from cornea should also avoid using this product
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not use topical antibiotics to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to a secondary infection (take appropriate measures if superinfection occurs)
Follow-up
Further Outpatient Care
- Patients should be followed within 2-4 weeks of institution of medical therapy to assess response to therapy and need for surgical incision and curettage.
Deterrence/Prevention
- Try to prevent recurrences by minimizing or eliminating risk factors, such as blepharitis and meibomian gland dysfunction, through daily lid hygiene and warm compresses.
Complications
- Large lesions of the upper eyelid have been reported to cause decreased vision secondary to induced astigmatism or hyperopia resulting from central corneal flattening.
Prognosis
- Hordeola are usually self-limited and spontaneously resolve within 1-2 weeks. The resolution is hastened with the use of warm compresses and lid hygiene.
- Internal hordeola may occasionally evolve into chalazia, which may require topical or intralesional steroids or even incision and curettage.
Patient Education
- For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education articles Chalazion (Lump in Eyelid) and Sty.
Miscellaneous
Medicolegal Pitfalls
- Basal cell carcinoma or sebaceous cell carcinoma of the eyelid can be misdiagnosed clinically as a recurrent hordeolum or chalazion. In these cases, a high degree of clinical suspicion should be present, and histopathologic examination of the surgical specimen is important in determining the diagnosis.
References
American Academy of Ophthalmology. Infectious diseases of the external eye: clinical aspects. In: External Disease and Cornea. 8. San Francisco, CA: LEO; 2006-2007.
American Academy of Ophthalmology. Eyelids. In: Ophthalmic Pathology and Intraocular Tumors. 4. San Francisco, CA: LEO; 2007-2008.
Destafeno JJ, Kodsi SR, Primack JD. Recurrent Staphylococcus aureus chalazia in hyperimmunoglobulinemia E (Job's) syndrome. Am J Ophthalmol. Dec 2004;138(6):1057-8. [Medline].
Hosal BM, Zilelioglu G. Ocular complication of intralesional corticosteroid injection of a chalazion. Eur J Ophthalmol. Nov-Dec 2003;13(9-10):798-9. [Medline].
Katowitz WR, Shields CL, Shields JA, Eagle RC Jr, Mulvey LD. Pilomatrixoma of the eyelid simulating a chalazion. J Pediatr Ophthalmol Strabismus. Jul-Aug 2003;40(4):247-8. [Medline].
Kiratli HK, Akar Y. Multiple recurrent hordeola associated with selective IgM deficiency. J AAPOS. 2001;5(1):60-1. [Medline].
Lederman C, Miller M. Hordeola and chalazia. Pediatr Rev. Aug 1999;20(8):283-4. [Medline].
Raskin EM, Speaker MG, Laibson PR. Blepharitis. Infect Dis Clin North Am. Dec 1992;6(4):777-87. [Medline].
Shields JA, Demirci H, Marr BP, Eagle RC Jr, Shields CL. Sebaceous carcinoma of the eyelids: personal experience with 60 cases. Ophthalmology. Dec 2004;111(12):2151-7. [Medline].
Keywords
hordeola, external hordeola, internal hordeola, chalazion, chalazia, stye, styes, eyelid disorder, eyelid infection
Contributor Information and Disclosures
Author
Michael P Ehrenhaus, MD, Director, Department of Cornea, External Disease & Refractive Surgery, Assistant Professor, Department of Ophthalmology, State University of New York Downstate Medical Center
Michael P Ehrenhaus, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, and Contact Lens Association of Ophthalmologists
Disclosure: Nothing to disclose.
Coauthor(s)
Kirk Alexander Sturridge, MD, Staff Physician, Department of Ophthalmology, State University of New York Downstate Medical Center
Disclosure: Nothing to disclose.
Medical Editor
Fernando H Murillo-Lopez, MD, Senior Surgeon, Unidad Privada de Oftalmologia CEMES
Fernando H Murillo-Lopez, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.
Pharmacy Editor
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.
Managing Editor
Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching
CME Editor
Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.
Chief Editor
Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.