Hordeolum (Stye)

A hordeolum is an acute infection affecting the meibomian, Zeiss, or Moll glands of the eyelid. Stasis of the gland secretions predisposes to bacterial infection. Staphylococcus aureus is the most common pathogen. The condition presents as a painful, localized, erythematous mass in the anterior (external hordeolum) or posterior (internal hordeolum) lamella of the eyelid. A hordeolum usually resolves spontaneously and can be managed with warm compresses, massage, and lid hygiene. In certain cases of significant swelling, topical antibiotics with steroids may be needed. If there is no resolution, incision, and drainage are performed.

Last update:

Table of Contents

Share this concept:

Share on facebook
Share on twitter
Share on linkedin
Share on reddit
Share on email
Share on whatsapp

Overview

Anatomy

  • Eyelids:
    • Protect the eyes from injury and light
    • Anterior portion: 
      • Composed of orbicularis oculi muscle and skin 
      • Appendages (eyelashes, Zeiss and Moll glands)
    • Posterior portion: 
      • Palpebral conjunctiva and tarsal plate 
      • Meibomian glands
  • Eyelid glands:
    • Gland of Moll: 
      • Modified sweat glands 
      • Orifice between adjacent lashes
    • Gland of Zeis: 
      • Sebaceous gland 
      • Orifice into the eyelash follicle
      • Sebum has antiseptic activity against bacteria.
    • Meibomian glands:
      • Modified sebaceous glands with openings behind the eyelashes
      • 20–25 glands per eyelid
      • Meibum (lipid-rich secretion): prevents evaporation of tears and evens out tear film over the surface of the eye
      • Immunoglobulin A, mucin 1, and lysosomes in secretion: defense against infection
Sagittal cut of the upper eye lid

Sagittal cut of the upper eyelid

Image by Lecturio.

Hordeolum

  • Acute infection, commonly from bacterial source, of the gland(s) in the eyelid
  • Also called a stye 
  • Categories:
    • External hordeolum in the anterior eyelid lamella (superficial layers) affects the glands of Zeiss and Moll.
    • Internal hordeolum in the posterior eyelid lamella affects the meibomian glands.
Table: Eyelid glands
NameTypeOpening locationInfection
Gland of ZeisSebaceous glandDirectly into the eyelash follicleInternal hordeolum
Gland of MollModified sweat glandsBetween adjacent lashesInternal hordeolum
Meibomian glandModified sebaceous glandBehind eyelashesExternal hordeolum

Etiology

  • Risk factors:
    • Skin disorders (e.g., rosacea and seborrheic dermatitis) involving the eyelids 
    • Drying or stasis of the Zeis, Moll, and meibomian gland secretions → reduced defenses against infection
    • Eye makeup (may be contaminated by bacteria)
    • Past history of similar eyelid lesions
    • Diabetes
  • Frequently caused by infection of the glands: Staphylococcus aureus (most common pathogen)

Clinical Presentation

  • Symptoms:
    • Painful localized mass at the margin of the eyelid or on the conjunctival side of the eyelid
    • Initially, can have generalized lid edema until it localizes
    • Depending on size and location, lesion could obstruct part of the visual field.
  • Examination:
    • Tender localized erythematous eyelid mass that may or may not have drainage
    • Visual acuity: may be affected if lesion is large enough
    • Extraocular muscles movements: intact and painless
    • To locate an internal hordeolum: perform eyelid eversion

Complications

  • Chalazion:
    • Can result from hordeolum once inflammation subsides
    • A nontender, rubbery nodule arising from obstruction of the meibomian and Zeis glands
    • If small, will resolve spontaneously
  • Conjunctivitis:
    • Internal hordeolum: may cause conjunctival inflammation (when it irritates the conjunctival side)
  • Infection may spread beyond the eyelid glands:
    • Preseptal cellulitis:
      • Infectious inflammation of the structures anterior to the orbital septum (skin and subcutaneous tissue) 
      • Presents with pain, fever, swelling, redness, and discharge
    • Orbital cellulitis: 
      • Infectious inflammation of the structures posterior to the orbital septum (orbital fat, muscles, bone)
      • Presents with pain, fever, redness, discharge, swelling, proptosis, diplopia, and abnormal eye movement
Orbital cellulitis

Photograph showing orbital cellulitis, a bacterial infection of the periocular tissues.

Image: “Orbital cellulitis” by Jonathan Trobe. License: CC BY 3.0

Treatment

Most hordeola resolve spontaneously, lasting up to 1–2 weeks.

  • Conservative management:
    • Warm compresses:
      •  Facilitate abscess drainage and relieve symptoms
      • Applied for 15 minutes 4 times a day until resolution
    • Massage therapy and lid scrubs to clear debris
  • Topical antibiotic/steroid ointment:
    • If initial management fails
    • If with significant swelling (causing corneal pressure)
  • Systemic antibiotics: if associated with preseptal or orbital cellulitis
  • Incision and drainage: may be needed if the stye does not improve within 7–14 days

Differential Diagnosis

  • Conjunctivitis: inflammation of the conjunctiva, the outer lining of the eye. Etiology can be infectious or non-infectious. Patients present with redness and discharge in 1 or both eyes. Bacterial conjunctivitis often has purulent discharge, whereas viral causes have watery discharge.
  • Chalazion: a firm, non-tender mass at the eyelid resulting from obstruction of the Zeis or meibomian glands. The condition is usually managed conservatively with warm compresses. Persistence of the lesion requires incision and curettage or glucocorticoid injection by an ophthalmologist.
  • Dacryocystitis: inflammation of the nasolacrimal sac commonly caused by duct obstruction. Presents as redness and swelling in the area of the tear duct. When infected, dacryocystitis has mucopurulent discharge. Initial management includes warm compresses and antibiotics if indicated. For persistent obstruction, nasolacrimal duct intubation and other surgical interventions are performed.

References

  1. Bragg, K., Le, P., Le, J. (2020). Hordeolum. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK441985/
  2. Ehrenhaus, M., Ing, E. (2018). Hordeolum. Medscape. https://emedicine.medscape.com/article/1213080-overview
  3. Ghosh, C., Ghosh, T. (2020). Eyelid lesions. UpToDate. Retrieved 25 Oct 2020, from https://www.uptodate.com/contents/eyelid-lesions?search=hordeolum&source=search_result&selectedTitle=1~25&usage_type=default&display_rank=1#H130613690

🍪 Lecturio is using cookies to improve your user experience. By continuing use of our service you agree upon our Data Privacy Statement.

Details