Hordeolum 

Updated: Nov 19, 2018
Author: Michael P Ehrenhaus, MD; Chief Editor: Edsel Ing, MD, MPH, FRCSC 

Overview

Background

A hordeolum is a common disorder of the eyelid.[1] 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).[2]

"Hordeum" is Latin for barley, the appearance of which a hordeolum can resemble.

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.[3] 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.[4] 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.[5]

Epidemiology

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.

 

Presentation

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.[6]

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.[4]

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.[6]

Causes

Hordeola are associated with S aureus infection.[3]

Patients with chronic blepharitis, meibomian gland dysfunction, and ocular rosacea are at greater risk of developing hordeola than the general population.[6]

There are published case reports where multiple recurrent hordeola have been associated with selective immunoglobulin M (IgM) deficiency.[7]

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.

 

DDx

Differential Diagnoses

 

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.[8]

 

Treatment

Medical Care

Hordeola are usually self-limited, spontaneously improving in 1-2 weeks.

Medical therapy for hordeola includes eyelid hygiene (lid scrubs), warm compresses 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.[9, 10] Nonsurgical remedies for hordeolum, although unproven,[11] do not seem to be harmful.

If an external hordeolum is centered around a lash follicle, the lash can be pulled to enhance drainage.

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. There is little to no evidence to suggest that acupuncture is beneficial.[12]

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

Medication Summary

The goals of pharmacotherapy are to treat the infection, to reduce morbidity, and to prevent complications.

Antibiotics

Class Summary

A course of oral antibiotics is indicated if the hordeolum is complicated by preseptal cellulitis.

Cephalexin (Keflex)

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.

Erythromycin base (Ery-Tab, PCE, E.E.S. 400)

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.

Amoxicillin/clavulanate (Augmentin, Augmentin ES-600, Augmentin XR, Amoclan)

Amoxicillin inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins. Addition of clavulanate inhibits beta-lactamase–producing bacteria. Good alternative antibiotic for patients allergic to or intolerant to macrolides. Usually is well tolerated and provides good coverage for most infectious agents.

Doxycycline (Morgidox, Adoxa, Oracea)

Doxycycline inhibits protein synthesis and, therefore, bacterial growth by binding with 30S and possibly 50S ribosomal subunits of susceptible bacteria. May be added if there is history of multiple or recurrent lesions or if there is significant and chronic meibomitis.

 

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.

Granulation tissue may sometimes occur after the hordeolum resolves.

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.[13]

Patient Education

For excellent patient education resources, visit eMedicineHealth's Eye and Vision Center. Also, see eMedicineHealth's patient education articles Chalazion (Lump in Eyelid) and Sty.

 

Questions & Answers