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
- Gland of Moll:
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.
| 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 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
Man suffering from external hordeolum of the lower lid.
Image: “Stye” by Palosirkka. License: CC0 1.0
Upper eyelid stye, illustrating a localized erythematous and swollen area.
Image: “Stye” by Andre Riemann. License: Public Domain
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
- Preseptal cellulitis:
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
- Warm compresses:
- 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
- Bragg, K., Le, P., Le, J. (2020). Hordeolum. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK441985/
- Ehrenhaus, M., Ing, E. (2018). Hordeolum. Medscape. https://emedicine.medscape.com/article/1213080-overview
- 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
