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 Staphylococcus Staphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora. 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.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

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Overview

Anatomy

  • Eyelids:
    • Protect the eyes from injury and light
    • Anterior portion: 
      • Composed of orbicularis oculi muscle and skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the 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 Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology: Overview.
    • 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
Name Type Opening location Infection
Gland of Zeis Sebaceous gland Directly into the eyelash follicle Internal hordeolum
Gland of Moll Modified sweat glands Between adjacent lashes Internal hordeolum
Meibomian gland Modified sebaceous gland Behind eyelashes External hordeolum

Etiology

  • Risk factors:
    • Skin disorders (e.g., rosacea Rosacea Rosacea is a chronic inflammatory disease of the skin that is associated with capillary hyperreactivity. This condition is predominantly seen in middle-aged women, and is more common in fair-skinned patients. Rosacea and seborrheic dermatitis Seborrheic dermatitis Seborrheic dermatitis is a common chronic, relapsing skin disorder that presents as erythematous plaques with greasy, yellow scales in susceptible areas (scalp, face, and trunk). Seborrheic dermatitis has a biphasic incidence, occurring in two peaks: first in infants, then in adolescence and early adulthood. 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 Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology: Overview)
    • Past history of similar eyelid lesions
    • Diabetes
  • Frequently caused by infection of the glands: Staphylococcus Staphylococcus Staphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora. 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 Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). 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 Chalazion A chalazion is one of the most common inflammatory lesions of the eyelid. It is caused by obstruction of the Meibomian or Zeis glands, leading to granulomatous inflammation and resulting in a firm, rubbery, slow-growing nodule that is typically non-tender. Chalazion:
    • Can result from hordeolum once inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation subsides
    • A nontender, rubbery nodule arising from obstruction of the meibomian and Zeis glands
    • If small, will resolve spontaneously
  • Conjunctivitis Conjunctivitis Conjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis:
    • Internal hordeolum: may cause conjunctival inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation (when it irritates the conjunctival side)
  • Infection may spread beyond the eyelid glands:
    • Preseptal cellulitis Preseptal cellulitis Orbital and preseptal cellulitis are infections differentiated by the anatomic sites affected in the orbit. Infection anterior to the orbital septum is preseptal cellulitis. Inoculation with the pathogen can occur through trauma or surgery. Cellulitis also occurs via extension from a nearby structure (such as from sinus infection or sinusitis). Orbital and Preseptal Cellulitis:
      • Infectious inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the structures anterior to the orbital septum ( skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin and subcutaneous tissue) 
      • Presents with pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, swelling, redness, and discharge
    • Orbital cellulitis Orbital cellulitis Orbital and preseptal cellulitis are infections differentiated by the anatomic sites affected in the orbit. Infection posterior to the septum is orbital cellulitis. Inoculation with the pathogen can occur through trauma or surgery. Cellulitis also occurs via extension from a nearby structure (such as from sinus infection or sinusitis). Orbital and Preseptal Cellulitis
      • Infectious inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the structures posterior to the orbital septum (orbital fat, muscles, bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones)
      • Presents with pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, redness, discharge, swelling, proptosis, diplopia, and abnormal eye movement
Orbital cellulitis

Photograph showing orbital cellulitis Cellulitis Cellulitis is a common infection caused by bacteria that affects the dermis and subcutaneous tissue of the skin. It is frequently caused by Staphylococcus aureus and Streptococcus pyogenes. The skin infection presents as an erythematous and edematous area with warmth and tenderness. Cellulitis, a bacterial infection of the periocular tissues.

Image: “ Orbital cellulitis Orbital cellulitis Orbital and preseptal cellulitis are infections differentiated by the anatomic sites affected in the orbit. Infection posterior to the septum is orbital cellulitis. Inoculation with the pathogen can occur through trauma or surgery. Cellulitis also occurs via extension from a nearby structure (such as from sinus infection or sinusitis). Orbital and Preseptal 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 Cellulitis Cellulitis is a common infection caused by bacteria that affects the dermis and subcutaneous tissue of the skin. It is frequently caused by Staphylococcus aureus and Streptococcus pyogenes. The skin infection presents as an erythematous and edematous area with warmth and tenderness. Cellulitis
  • Incision and drainage: may be needed if the stye does not improve within 7–14 days

Differential Diagnosis

  • Conjunctivitis Conjunctivitis Conjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the conjunctiva, the outer lining of the eye. Etiology can be infectious or non-infectious. Patients present with redness and discharge in one or both eyes. Bacterial conjunctivitis often has purulent discharge, whereas viral causes have watery discharge.
  • Chalazion Chalazion A chalazion is one of the most common inflammatory lesions of the eyelid. It is caused by obstruction of the Meibomian or Zeis glands, leading to granulomatous inflammation and resulting in a firm, rubbery, slow-growing nodule that is typically non-tender. 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 Dacryocystitis Dacryocystitis is inflammation of the lacrimal sac due to nasolacrimal duct obstruction and the subsequent stasis of tears. The condition can have an acute or chronic onset. Acute dacryocystitis presents within hours or days with redness, swelling, tenderness, and excessive tearing. Dacryocystitis: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. 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

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