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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 Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast 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 Warm Compresses Chalazion, massage, and lid hygiene. In certain cases of significant swelling Swelling Inflammation, topical antibiotics with steroids Steroids A group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus. Benign Liver Tumors may be needed. If there is no resolution, incision, and drainage are performed.

Last updated: 28 Jan, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Anatomy

  • Eyelids Eyelids Each of the upper and lower folds of skin which cover the eye when closed. Blepharitis:
    • Protect the eyes from injury and light
    • Anterior portion: 
      • Composed of orbicularis oculi Orbicularis oculi Facial Muscles: Anatomy 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. Skin: Structure and Functions 
      • Appendages (eyelashes, Zeiss and Moll glands)
    • Posterior portion: 
  • Eyelid glands Eyelid Glands Blepharitis:
    • Gland of Moll Gland of Moll Blepharitis
      • Modified sweat glands Sweat glands Sweat-producing structures that are embedded in the dermis. Each gland consists of a single tube, a coiled body, and a superficial duct. Soft Tissue Abscess 
      • Orifice between adjacent lashes
    • Gland of Zeis: 
      • Sebaceous gland 
      • Orifice into the eyelash follicle
      • Sebum Sebum The oily substance secreted by sebaceous glands. It is composed of keratin, fat, and cellular debris. Infectious Folliculitis 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.
    • Meibomian glands:
      • Modified sebaceous glands with openings behind the eyelashes
      • 20–25 glands per eyelid
      • Meibum Meibum Blepharitis (lipid-rich secretion Secretion Coagulation Studies): prevents evaporation of tears and evens out tear film over the surface of the eye
      • Immunoglobulin A, mucin 1, and lysosomes Lysosomes A class of morphologically heterogeneous cytoplasmic particles in animal and plant tissues characterized by their content of hydrolytic enzymes and the structure-linked latency of these enzymes. The intracellular functions of lysosomes depend on their lytic potential. The single unit membrane of the lysosome acts as a barrier between the enzymes enclosed in the lysosome and the external substrate. The activity of the enzymes contained in lysosomes is limited or nil unless the vesicle in which they are enclosed is ruptured or undergoes membrane fusion. The Cell: Organelles in secretion Secretion Coagulation Studies: defense against infection
Sagittal cut of the upper eye lid

Sagittal Sagittal Computed Tomography (CT) 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 Eyelid Glands Blepharitis
Name Type Opening location Infection
Gland of Zeis Sebaceous gland Directly into the eyelash follicle External hordeolum
Gland of Moll Gland of Moll Blepharitis Modified sweat glands Sweat glands Sweat-producing structures that are embedded in the dermis. Each gland consists of a single tube, a coiled body, and a superficial duct. Soft Tissue Abscess Between adjacent lashes External hordeolum
Meibomian gland Meibomian Gland Chalazion Modified sebaceous gland Behind eyelashes Internal hordeolum

Etiology

  • Risk factors:
    • 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. Skin: Structure and Functions 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 Eyelids Each of the upper and lower folds of skin which cover the eye when closed. Blepharitis 
    • Drying or stasis of the Zeis, Moll, and meibomian gland Meibomian Gland Chalazion 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)
    • Past history of similar eyelid lesions
    • Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
  • 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 Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast 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 Visual Field The Visual Pathway and Related Disorders.
  • Examination:
    • Tender localized erythematous eyelid mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast that may or may not have drainage
    • Visual acuity Visual Acuity Clarity or sharpness of ocular vision or the ability of the eye to see fine details. Visual acuity depends on the functions of retina, neuronal transmission, and the interpretative ability of the brain. Normal visual acuity is expressed as 20/20 indicating that one can see at 20 feet what should normally be seen at that distance. Visual acuity can also be influenced by brightness, color, and contrast. Ophthalmic Exam: may be affected if lesion is large enough
    • Extraocular muscles movements: intact and painless
    • To locate an internal hordeolum: perform eyelid eversion Eversion Chronic Apophyseal Injury

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 Nodule Chalazion arising from obstruction of the meibomian and Zeis glands Zeis Glands Chalazion
    • 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 Eyelid Glands Blepharitis:
    • Preseptal 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:
      • Infectious Infectious Febrile Infant 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 Orbital Septum Orbital and Preseptal Cellulitis ( 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. Skin: Structure and Functions and subcutaneous tissue Subcutaneous tissue Loose connective tissue lying under the dermis, which binds skin loosely to subjacent tissues. It may contain a pad of adipocytes, which vary in number according to the area of the body and vary in size according to the nutritional state. Soft Tissue Abscess
      • Presents with pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, 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 Swelling Inflammation, redness Redness Inflammation, and discharge
    • 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
      • Infectious Infectious Febrile Infant 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 Septum Orbital and Preseptal Cellulitis (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. Bones: Structure and Types)
      • Presents with pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, 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 Redness Inflammation, discharge, swelling Swelling Inflammation, proptosis Proptosis Retinoblastoma, diplopia Diplopia A visual symptom in which a single object is perceived by the visual cortex as two objects rather than one. Disorders associated with this condition include refractive errors; strabismus; oculomotor nerve diseases; trochlear nerve diseases; abducens nerve diseases; and diseases of the brain stem and occipital lobe. Myasthenia Gravis, 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 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” by Jonathan Trobe. License: CC BY 3.0

Treatment

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

  • Conservative management:
    • Warm compresses Warm Compresses Chalazion:
      •  Facilitate abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease 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 Swelling Inflammation (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 Incision And Drainage Chalazion: 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 Conjunctiva The mucous membrane that covers the posterior surface of the eyelids and the anterior pericorneal surface of the eyeball. Eye: Anatomy, the outer lining of the eye. Etiology can be infectious Infectious Febrile Infant or non- infectious Infectious Febrile Infant. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present with redness Redness Inflammation and discharge in one or both eyes Both Eyes Refractive Errors. Bacterial 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 often has purulent discharge Purulent Discharge Dacryocystitis, 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 Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast at the eyelid resulting from obstruction of the Zeis or meibomian glands. The condition is usually managed conservatively with warm compresses Warm Compresses Chalazion. Persistence of the lesion requires incision and curettage Curettage A scraping, usually of the interior of a cavity or tract, for removal of new growth or other abnormal tissue, or to obtain material for tissue diagnosis. It is performed with a curet (curette), a spoon-shaped instrument designed for that purpose. Benign Bone Tumors 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 Redness Inflammation and swelling Swelling Inflammation in the area of the tear duct. When infected, 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 has mucopurulent discharge. Initial management includes warm compresses Warm Compresses Chalazion and antibiotics if indicated. For persistent obstruction, nasolacrimal duct Nasolacrimal Duct Nasolacrimal duct. Dacryocystitis intubation Intubation Peritonsillar Abscess 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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