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Understanding the self-limiting nature of a hordeolum, an acute bacterial infection of the eyelid, is crucial for healthcare professionals. Patients often present with this common condition, which manifests as a painful, erythematous eyelid inflammation. Whether it forms on the external eyelid, commonly known as a stye, or on the inner eyelid, which can be mistaken for a chalazion, a hordeolum often resolves independently within one to two weeks. This underscores the importance of conservative management, a reassuringly practical approach that typically involves warm compresses and massage therapy; topical antibiotics and drainage are rare interventions (Lindsley K et al., 2017; Willmann D. et al., 2023).
A hordeolum is usually caused by a Staphylococcus infection in the eyelash hair follicle. An external hordeolum results from a blockage of the sebaceous (Zeis) or sweat (Moll) glands, occurring at the lash line and manifesting as a painful, red, swollen area that develops into an abscess. An internal hordeolum is caused by a blockage of the Meibomian glands, with the abscess forming on the inner surface of the eyelids. Hordeola may appear on the upper and lower eyelids (Willmann D. et al., 2023; Crozier, MBHK. et al., 2021).
While hordeola is very common, its exact incidence is unknown. Their prevalence does not directly correlate with race, sex, or gender. Adults may have a higher tendency to develop hordeola due to thicker sebum. Individuals with chronic conditions such as rosacea, blepharitis, seborrheic dermatitis, diabetes, and elevated lipids are also at an elevated risk for developing hordeola (Willmann D., 2023).
The infection occurs due to thickening, drying, or stagnation of secretions from the Zeis, Moll, or Meibomian glands. The Zeis and Moll glands are the ciliary glands of the eye. The Zeis gland secretes sebum with antiseptic properties that help inhibit bacterial growth. In contrast, the Moll gland secretes immunoglobulin A, lysosomes, and mucin 1, vital in the immune defense against eye infections. When these glands become clogged or blocked, the eye's defenses are compromised, leading to bacterial infections, most commonly caused by Staphylococcus aureus. This results in a localized inflammatory response with leukocyte infiltration, eventually forming a purulent pocket or abscess (Crozier, MBHK. et al. 2021).
Typically, there is no need for diagnostic testing when diagnosing a hordeolum as it is usually a clinical diagnosis. Colonization with noninvasive bacteria is common, and bacterial cultures of discharge from the area usually do not correlate with clinical improvement or aid in treatment. Rarely, further testing and imaging might be necessary if complications occur, such as the infection spreading and causing periorbital or orbital cellulitis. Occasionally, an internal hordeolum may lead to corneal irritation, prompting the use of fluorescein staining to check for corneal abrasion (Willmann D. et al., 2023).
While lesions can often drain spontaneously without treatment, warm compresses and massage to the area are beneficial and considered the gold standard of treatment. As a healthcare professional, it's important to advise patients on using warm compresses and massage correctly. Warm compresses help soften the granulomatous tissue and facilitate drainage. At the same time, eyelid massage aims to help express the purulent drainage from the infected gland. Eyelid scrubs with saline or mild, tear-free, pH-balanced shampoo (such as baby shampoo) may promote drainage by clearing debris from the clogged duct. However, it's crucial to advise patients to avoid wearing makeup and contact lenses until the infection has healed to prevent further complications. Care should also be taken with compresses and massage for the internal hordeolum to avoid causing irritation or deformation to the cornea. Patients must also be advised to never squeeze a stye (Crozier, MBHK., et al. 2021; Willmann D. et al. 2023).
While hordeolum is common, it is crucial to make a correct diagnosis to ensure it is not mistaken for other manifestations of a painful red eyelid. Vigilance and thoroughness in considering differential diagnoses, including chalazion, blepharitis, squamous cell carcinoma, sebaceous gland carcinoma, idiopathic facial aseptic granuloma, pneumo-orbita, periorbital and orbital cellulitis, are essential. Addressing these underlying conditions is crucial to prevent recurrent hordeolum in these patient populations, empowering healthcare professionals to take a proactive role in patient care (Ozer PA et al., 2016).
Hordeolum is a condition often encountered by emergency physicians, nurse practitioners, and primary care providers. While conservative treatment effectively manages the infection in most cases, it's crucial to make a correct diagnosis and refer the patient to an ophthalmologist for persistent or more extensive lesions or when the cause is unclear. This responsible and caring approach ensures comprehensive patient care and should instill confidence in healthcare professionals, as the ophthalmologist can perform the necessary incision and drainage under local anesthesia and ensure the specimen is sent to pathology to rule out more serious diseases, including carcinoma (Willmann D. et al., 2023).
References
Lindsley K, Nichols JJ, Dickersin K, (2017). Non-surgical interventions for acute internal hordeolum. The Cochrane Database of Systematic Reviews. 2017 Jan;1:CD007742. DOI: 10.1002/14651858.cd007742.pub4. PMID: 28068454; PMCID: PMC5370090.
Willmann D, Guier CP, Patel BC, Scott WM, (2023). Hordeolum (Stye). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459349/
Crozier MBHK, Giles SM. BSc, MD., (2021) The occasional eyelid lesion. Canadian Journal of Rural Medicine 26(2):p 80-86, Apr-Jun 2021. | DOI: 10.4103/CJRM.CJRM_66_20
Ozer PA, Gurkan A, Kurtul BE, Kabatas EU, Beken S, (2016). Comparative Clinical Outcomes of Pediatric Patients Presenting with Eyelid Nodules of Idiopathic Facial Aseptic Granuloma, Hordeola, and Chalazia. Journal of Pediatric Ophthalmology and Strabismus. 2016 Jul;53(4):206-211. DOI: 10.3928/01913913-20160511-03. PMID: 27182747.
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