Hordeolum (Stye)

Etiology

Hordeola arise from an acute bacterial infection of the sebaceous glands of the eyelid. Around 90% to 95% of the lesions are due to Staphylococcus aureus, with Staphylococcus epidermidis being the 2nd most common cause. An external hordeolum represents a localized abscess formation of the follicle of an eyelash, whereas an internal hordeolum is an acute bacterial infection of the meibomian glands of the eyelid.[11][12]

In contrast, a chalazion is an acute or chronic eyelid inflammation secondary to an obstruction of the tarsal plate's oil glands (meibomian or Zeis) alongside a foreign body reaction to sebum. Conditions that block the normal drainage of sebaceous glands, such as hordeola, acne rosacea, and blepharitis, can contribute to the development of chalazia.[13]

Hordeolum Risk Factors

The key factors contributing to stye formation:

• Bacterial infection: S aureus is the primary causative organism for most styes. However, other bacteria, such as S epidermidis or, less commonly, streptococcal species, may also be involved.
• Glandular involvement: An external hordeolum results from an infection of the glands of Zeis (sebaceous glands at the base of eyelash follicles) or Moll (modified sweat glands). An internal hordeolum is a deeper infection involving the meibomian glands within the tarsal plate.
• Predisposing factors: Conditions that increase a person's vulnerability to hordeolum formation include:
  • Inadequate cleaning of the eyelid margins promotes bacterial colonization and blockage of sebaceous glands.
  • Chronic eyelid conditions like blepharitis and meibomian gland dysfunction can also cause hordeola. Blepharitis leads to obstruction of eyelid glands. Meibomian gland dysfunction also contributes to stye formation.[14]
  • Systemic conditions that may increase susceptibility to stye formation include diabetes and rosacea. Diabetes increases susceptibility to infections due to impaired immune function. Chronic inflammation in rosacea affects meibomian gland function.
  • Improper contact lens hygiene introduces bacteria to the eyelid margin, raising the risk of styes.[15]
  • Frequent eye makeup use blocks sebaceous glands. Poor eye makeup removal practices encourage bacterial growth.
  • Stress weakens the immune system, predisposing individuals to styes. Similarly, immunosuppression from conditions like HIV or chemotherapy heightens vulnerability.[16]

Mechanism of Stye Formation

The combination of gland obstruction, whether due to meibomian dysfunction, debris, inflammation, or bacterial colonization, results in acute inflammation of the gland. A localized abscess also forms, manifesting with redness, swelling, and tenderness.

By addressing the underlying causes and predisposing factors, clinicians can effectively prevent styes and manage recurrent cases.[17]

Epidemiology

While hordeola are very common, the exact incidence is unknown. Every age and demographic is affected, although a slightly increased incidence is observed among patients aged 30 to 50. Prevalence differences among populations worldwide are unknown. Patients with chronic conditions such as seborrhoeic dermatitis, diabetes, and hyperlipidemia may also be at increased risk.[18][19]

Prevalence in Different Regions

Styes are common worldwide, affecting individuals of all ages. While the exact prevalence is not well-documented, the occurrence is significantly influenced by risk factors such as poor eyelid hygiene, blepharitis, and meibomian gland dysfunction. Styes are more frequently observed in regions with poor access to healthcare or suboptimal hygiene practices.[20]

Sex Distribution

Styes are slightly more common in female individuals. This trend is attributed to the frequent use of cosmetics and eye makeup in this group, which can block gland ducts and exacerbate bacterial colonization.[21]

Age Distribution

Styes can occur in all age groups, but certain factors increase the risk for some individuals. Frequent eye rubbing and inadequate eyelid hygiene can make children and adolescents vulnerable to developing a stye. Conditions that increase susceptibility to hordeolum formation in adults include chronic blepharitis, rosacea, and meibomian gland dysfunction. Age-related changes in meibomian gland function and tear production can cause recurrent styes in older adults.[22]

Associated Risk Factors

Styes are more frequent in individuals with the following conditions:

• Blepharitis, which causes chronic eyelid inflammation
• Diabetes, which impairs the immune response
• Rosacea, which affects meibomian gland function and increases susceptibility to eyelid infections [23]

By understanding the epidemiology of styes, healthcare providers can better identify at-risk populations and emphasize preventive strategies, including proper eyelid hygiene and timely treatment of underlying conditions.[24]

Pathophysiology

S aureus infection contributes to the development of a hordeolum, the manifestations of which depend on which of the eyelid gland types is affected. Involvement of the Zeis and Moll glands, also known as the ciliary glands, causes pain and swelling at the base of the eyelash, often with localized abscess formation. This condition, termed "external hordeolum," produces the typical appearance of a stye, with a localized pustule at the eyelid margin. The meibomian glands, which are modified sebaceous glands located within the eyelid's tarsal plate, produce an oily layer that helps maintain proper eye lubrication. Acute meibomian gland infection produces an internal hordeolum. Due to its deeper location within the eyelid, an internal hordeolum has a less defined appearance compared to an external hordeolum.[25]

By comparison, chalazia develop due to mechanical obstruction and dysfunction of the meibomian glands, leading to stasis and blockage of sebum release. Lesions typically have a subacute to chronic course, presenting as painless nodules within the eyelid or along the lid margin.[26]

External and internal hordeola lead to blockage of the eyelid gland ducts, followed by neutrophilic infiltration, causing localized inflammation, abscess formation, and tenderness. The most common findings include redness, swelling, and tenderness localized to the eyelid margin. Occasionally, a visible pus point or discharge may develop, particularly in external hordeola. Timely management can prevent progression to complications like preseptal cellulitis or chalazion formation.[27]

Histopathology

Key Features

Histopathological examination is not routinely performed for styes but may be considered in atypical, persistent, or recurrent cases to rule out malignancy or other underlying conditions. The key histological features typically observed in a stye include:

• Acute suppurative inflammation: Evidence of acute suppurative inflammation includes neutrophilic infiltration in and around the affected gland. The sebaceous glands of Zeis are involved in external hordeola, while the meibomian glands are affected in internal hordeola. Abscess formation with central necrosis may also be observed in advanced cases.[28]
• Edema and vascular congestion: Swelling and engorgement of nearby blood vessels occur due to the acute inflammatory response.
• Fibrosis: This feature is found in chronic or recurrent cases. Chronic inflammation is characterized by granulomatous reaction, and lipid-laden macrophages may be seen if the stye progresses to or coexists with a chalazion.
• Epithelial changes: Associated hyperplasia of the ductal epithelium or glandular tissue may arise due to chronic irritation. Debris or keratin plugs may occasionally block the gland openings.[29][30]

Differential Diagnoses Based on Histopathology

Histopathology can help differentiate a stye from other conditions. A chalazion is characterized by granulomatous inflammation and macrophages with minimal acute inflammation. Sebaceous gland carcinoma presents with atypical sebaceous cells, high mitotic activity, and infiltrative growth patterns, and it may clinically mimic a recurrent stye or chalazion. Basal cell carcinoma is identified by nodular or infiltrative basal cell proliferation with palisading nuclei at the lesion margins.

When to Perform Histopathology

Histopathological analysis is warranted for persistent or nonresolving lesions despite standard therapy, recurrent lesions in the same location, and atypical presentations suggesting malignancy, such as lack of tenderness, abnormal pigmentation, or lash loss. While histopathology is rarely necessary for typical styes, confirming the diagnosis and identifying complications or malignancies in atypical or suspicious cases remains crucial.

History and Physical

History

Patients with styes typically complain of a confined burning, tender swelling on one eyelid. Either the upper or lower lid may be involved (see Image. Lower Eyelid Hordeolum). In some cases, the complaint may start as generalized edema and erythema of the lid that later becomes localized. Patients frequently have a history of similar prior lesions of the eyelid. With an external hordeolum, pain, edema, and swelling are localized to a discrete eyelid area tender to palpation. The stye generally appears as a pustule with mild erythema of the lid margin. Pustular exudate may be present.[31]

Given the relatively larger size of a meibomian gland, patients with an internal hordeolum present with more diffuse tenderness and erythema of the lid. Diagnosis may be made by everting the lid to reveal a small pustule on the conjunctival surface. When the gland is infected without obstruction, an internal hordeolum may appear similar to an external hordeolum. Treatment for internal and external hordeola is the same, so differentiation of the lesions is not of significant clinical importance.[32]

In contrast to hordeola, chalazia have a more indolent and chronic presentation. Patients complain of nontender nodules of the eyelid with minimal to no surrounding erythema. In a persistent chalazion, chronic skin changes can develop around the underlying nodule.[33]

Patients with a hordeolum typically present with the following:

• Chief complaint: Patients with an internal hordeolum commonly have localized swelling, redness, and tenderness of the affected eyelid. Pain is often described as mild to moderate and confined to the area of the lesion. Many also report a foreign body sensation or irritation in the affected eye.[34]
• Associated symptoms: Accompanying manifestations include tearing, also known as epiphora, or watery discharge. Sensitivity to light, or photophobia, may occur in some cases. Blurred vision can arise if the swelling mechanically disrupts the visual axis.[35]
• Risk factors: Patients should be asked about contributing factors to internal hordeolum formation, such as poor eyelid hygiene, frequent eye rubbing, a history of blepharitis or meibomian gland dysfunction, and the use of eye makeup or contact lenses. Systemic conditions such as rosacea and diabetes mellitus also increase susceptibility. Weakened immunity due to stress or recent illnesses, such as an upper respiratory tract infection, can further predispose individuals to this condition.
• Chronicity: Establishing the onset of the condition is essential. The symptoms of an internal hordeolum are typically acute, lasting a few days to a week. However, recurrent episodes may indicate an underlying condition, such as chronic blepharitis or meibomian gland dysfunction.[36]

Physical Examination

A thorough eyelid and ocular examination often reveals the following findings:

• External inspection: Localized, red, and tender swelling is observed at the margin of the eyelid. An external hordeolum involves the glands of Zeis or Moll and appears as a superficial swelling near the lash line. An internal hordeolum involves the meibomian glands, presenting as a deeper swelling within the tarsal plate.[37]
• Palpation: The lesion is tender to touch and may feel fluctuant if pus is present. In cases of associated chalazion development, the lesion may feel firm upon palpation.[38]
• Examination of the conjunctivae and sclerae: Mild bulbar conjunctival injection, or redness, may be noted. Adjacent scleral areas are typically unaffected unless the infection has extended beyond the initial site.[39]
• Examination of the lid margin and gland openings: Signs of blocked meibomian gland openings or crusting may be observed, which is common in cases associated with blepharitis.[40]
• Visual acuity: Visual acuity is typically normal unless mechanical ptosis or significant swelling interferes with the visual axis.[41]
• Regional lymphadenopathy: Mild preauricular lymphadenopathy may occur in cases of associated secondary infection, though it is rare.[42]

Key differentiators include pain and tenderness, which are characteristic of styes and help distinguish them from a chalazion, which is painless and chronic. The acute onset of symptoms further sets styes apart from other chronic conditions, such as blepharitis and benign eyelid masses. By taking a detailed history and performing a focused physical examination, clinicians can confidently diagnose a stye and rule out other conditions that mimic its presentation.[43]

Evaluation

The evaluation of a stye is primarily clinical, relying on a detailed patient history and physical examination. However, additional diagnostic tests may be warranted in atypical or complicated cases to rule out other conditions or assess for complications. Below is a structured approach.

Clinical Examination

The primary diagnostic tool for styes is a careful clinical examination. History should include questions about the duration, pain, swelling, and any prior episodes. Risk factors such as eyelid hygiene, contact lens use, makeup practices, and any systemic conditions like diabetes or rosacea must be reviewed. During the physical examination, the eyelid must be inspected for a localized, tender, and swollen nodule. Look for signs of inflammation, including erythema, warmth, and purulent discharge. Also, evaluate for associated conditions like blepharitis or meibomian gland dysfunction.[44]

Laboratory Tests

Laboratory tests are rarely needed for uncomplicated styes but may be helpful in recurrent, atypical, or complicated cases. Microbiological testing is indicated if an atypical infection is suspected or the response to treatment is poor. Swabs from the lesion for gram stain and bacterial culture can identify causative organisms such as S aureus, and fungal cultures should be considered in immunocompromised patients.[45] Blood glucose or hemoglobin A1c (HbA1c) testing is recommended in patients with recurrent or severe styes to rule out undiagnosed diabetes.[46] A lipid profile may also be indicated in patients with recurrent chalazia or styes to assess for underlying dyslipidemia, which can contribute to meibomian gland dysfunction.[47]

Imaging Studies

Imaging is rarely required but may be useful in atypical or complicated cases. Ultrasound biomicroscopy may be helpful for evaluating deeper or atypical eyelid lesions when malignancy or abscess is suspected. Computed tomography (CT) or magnetic resonance imaging (MRI) is indicated when complications such as preseptal cellulitis and orbital cellulitis are suspected. CT with contrast is particularly valuable for differentiating between preseptal and orbital cellulitis.[48]

Differential Diagnosis Assessment

If a stye does not respond to typical treatment, additional evaluation may be necessary to rule out other conditions. For instance, sebaceous gland carcinoma may require a biopsy for a persistent or atypical lesion that fails to resolve with standard treatment. Additionally, chronic, nontender nodules could indicate a chalazion, which may need further assessment to confirm the diagnosis.[49]

National and International Guidelines

National and international guidelines provide a framework for the evaluation and management of styes to ensure effective diagnosis and treatment. The American Academy of Ophthalmology (AAO) recommends clinical evaluation as the primary method for diagnosing styes, reserving additional tests for atypical or recurrent cases. The Royal College of Ophthalmologists (RCOphth) suggests microbiological testing for cases with prolonged infections or poor response to antibiotics. The World Health Organization (WHO) emphasizes the importance of addressing underlying risk factors, such as hygiene and systemic conditions, to prevent recurrent styes.[50] Overall, adherence to these guidelines prioritizes patient safety, accurate diagnosis, and the prevention of complications.[51]

Other Considerations

Clinical examination suffices for the diagnosis and management of uncomplicated styes. For recurrent and atypical cases, laboratory tests (eg, cultures and glucose testing) and imaging (eg, CT and MRI) may be required.

Differentiating a stye from a chalazion requires only a history and physical examination. No diagnostic tests are typically required or useful in their 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. A recent chalazion may be challenging to differentiate from an internal hordeolum, but fortunately, management is the same.

Treatment / Management

Uncomplicated Hordeola

A stye is usually a self-limiting condition, with resolution occurring spontaneously within a week. Internal and external hordeola are treated similarly. Warm compresses and erythromycin ophthalmic ointment applied twice a day are usually sufficient to hasten recovery and prevent the spread of infection.

Little evidence demonstrates a benefit from topical antibiotics, but erythromycin ointment for 7 to 10 days has been recommended. Warm compresses should be applied for 15 minutes at least 4 times daily. Gentle massage of the nodule has also been suggested to assist in expressing the obstructed material. Oral antibiotics are rarely indicated unless significant surrounding erythema is present and periorbital cellulitis is a concern. Referral to an ophthalmologist is appropriate for very large hordeola, for which incision and drainage are considered. Reevaluation within 2 to 3 days is appropriate to assess treatment response.[52][53][54]

Chalazia

Conservative treatment is the mainstay of therapy for chalazia. Warm compresses and washing the affected eyelid with a gentle cleanser, such as baby shampoo, are usually the only measures required. Antibiotics are unnecessary since the etiology is inflammatory and not infectious. For cases that are recurrent or refractory to conservative treatment, combining intralesional corticosteroid injection with incision and curettage may be needed. These procedures necessitate referral to an ophthalmologist. Patients with chalazia should be referred to an ophthalmologist for nonurgent evaluation.[55]

Severe or Persistent Styes

Treatment for severe or persistent hordeola includes conservative measures, medical therapy, and surgical intervention. Below is a structured approach following both national and international guidelines.

Conservative management

For severe or persistent styes, conservative management remains the 1st-line approach. Applying a warm compress to the affected eyelid for 10 to 15 minutes, 3 to 4 times daily, helps promote drainage and relieve discomfort. The compress must be clean and not too hot to avoid burns. Maintaining eyelid hygiene by cleaning the eyelid margins with diluted baby shampoo or a commercial lid scrub can reduce debris and bacterial load. Patients should avoid touching or squeezing the lesion to prevent the spread of infection. Patients should also be advised to avoid using eye makeup and contact lenses while the infection has not resolved to prevent contamination and irritation.[56]

Medical treatment

Medical therapy is recommended for lesions that are moderate or associated with secondary infection. Topical antibiotics, such as erythromycin 0.5% or bacitracin, may be prescribed and applied 2 to 4 times daily to the eyelid margin to treat secondary bacterial infection. However, topical antibiotics are not always necessary for isolated styes.[57] Systemic antibiotics are indicated for preseptal cellulitis or widespread infection, with common choices including amoxicillin-clavulanate (500–875 mg orally twice daily) and doxycycline (100 mg orally once or twice daily). Doxycycline is also effective for associated meibomian gland dysfunction or rosacea.[58] Treatment typically lasts 7 to 10 days. Pain may be managed with over-the-counter analgesics, such as ibuprofen and acetaminophen.[59]

Surgical intervention

Surgical intervention is reserved for persistent or severe cases that do not respond to conservative or medical therapy. Incision and drainage may be performed by an ophthalmologist if the stye develops into an abscess or fails to resolve within 1 to 2 weeks. This procedure involves making a small incision to drain pus, offering immediate relief. For persistent lesions, particularly those evolving into chalazion, intralesional corticosteroid injection can be considered. Triamcinolone acetonide (0.05–0.2 mL of 10–40 mg/mL solution) can help reduce inflammation and expedite resolution.

Recurrent Styes

Addressing the underlying risk factors is important for patients with frequent recurrences. Long-term lid hygiene practices, such as regular warm compresses and cleaning, are essential for managing blepharitis or meibomian gland dysfunction. In chronic cases, low-dose doxycycline (eg, 20–40 mg once daily) may be considered.

Rosacea should be managed with systemic antibiotics, such as doxycycline, and dietary modifications, including increased intake of ω3 fatty acids. For patients with diabetes, optimizing glycemic control is crucial to reduce the risk of infection.

International Guidelines

Standards for the proper treatment and prevention of styes improve the quality of care given to affected individuals and reduce unnecessary medical interventions. The American Academy of Ophthalmology recommends conservative measures as the 1st-line treatment and emphasizes the limited role of antibiotics for uncomplicated styes. The Royal College of Ophthalmologists advises that incision and drainage should only be performed if conservative management fails. The World Health Organization highlights the importance of hygiene and public education to prevent infections related to poor eyelid hygiene.[60](A1)

Key Points

Important points to remember when caring for patients with hordeola include the following:

• Most styes resolve within 1 to 2 weeks with proper conservative care.
• Escalation to antibiotics or surgical intervention is warranted only in severe cases or those that fail the 1st-line treatment.
• Patient education on hygiene and risk factor management is critical to preventing recurrence.

Styes can be effectively managed with minimal complications by adhering to this approach.

Differential Diagnosis

A stye presents as a localized, painful, red, and swollen lesion on the eyelid. Conditions that can mimic this clinical entity must be ruled out to ensure accurate diagnosis and management. Below is a list of key differential diagnoses.

• Chalazion: A chalazion is a chronic, nontender, firm nodule resulting from the blockage of a meibomian gland. Chalazia are typically painless and do not present with acute inflammation, which distinguishes them from styes, which are acute. Chalazia are chronic and often follow the resolution of a hordeolum.
• Preseptal cellulitis: Preseptal cellulitis is a bacterial infection of the eyelid and periorbital tissues anterior to the orbital septum. This condition is characterized by diffuse eyelid swelling, redness, and tenderness but lacks a localized nodule or abscess. Unlike chalazia, preseptal cellulitis does not present with a fluctuant nodule or pus discharge and may be accompanied by systemic symptoms such as a low-grade fever.[61]
• Orbital cellulitis: This severe bacterial infection affects the tissues posterior to the orbital septum. Orbital cellulitis is distinguished by significant proptosis, restricted extraocular movement, and vision changes. Systemic symptoms such as high fever and malaise often accompany this pathology, making immediate imaging and hospitalization essential.
• Sebaceous gland carcinoma: This rare but serious malignant tumor of the sebaceous glands often mimics a recurrent chalazion or hordeolum. Key differentiating features include a persistent or recurrent lesion that does not respond to appropriate treatment and the presence of eyelid margin abnormalities such as loss of eyelashes (madarosis). A biopsy is required for definitive diagnosis.[62]
• Blepharitis: This condition involves inflammation of the eyelid margin, often due to bacterial infection or meibomian gland dysfunction. Blepharitis is characterized by diffuse redness and scaling along the lid margins, often involving both eyes. This chronic condition is marked by irritation and crusting rather than acute painful swelling.
• Dermoid cyst: This congenital lesion is commonly found along the orbital rim. A dermoid cyst is distinguished by being painless and noninflammatory, presenting as a firm and well-circumscribed mass.[63]
• Dacryocystitis: This condition involves infection of the lacrimal sac following obstruction of the nasolacrimal duct. Dacryocystitis presents with swelling, redness, and tenderness localized to the inner corner of the eye near the lacrimal sac, often accompanied by tearing or purulent discharge.[64]
• Herpes simplex and zoster ophthalmicus: Herpes simplex is caused by the herpes simplex virus, while herpes zoster ophthalmicus arises from the reactivation of the varicella-zoster virus. These viral infections lead to inflammation of the eyelid. Herpes simplex is characterized by vesicles on the eyelid, while herpes zoster presents as a vesicular rash along the trigeminal nerve distribution, often accompanied by crusting and pain.[65]
• Molluscum contagiosum: This viral infection is caused by the molluscum contagiosum virus, presenting as dome-shaped, pearly papules on the eyelid. The lesions are painless and feature a central umbilication, distinguishing them from other conditions. Unlike styes and chalazia, molluscum contagiosum lesions do not show signs of inflammation or acute tenderness.[66]

Accurate identification of the condition is essential to avoid inappropriate management, particularly with serious conditions like orbital cellulitis and sebaceous gland carcinoma, which require urgent treatment. When in doubt, referral to an ophthalmologist and additional investigations such as imaging or biopsy may be required. This structured approach ensures proper diagnosis and treatment while minimizing the risks of mismanagement.

Pertinent Studies and Ongoing Trials

Ongoing Studies

Currently, radiation therapy is not recommended for the treatment of styes, as this condition is typically managed with conservative measures or minor surgical interventions. However, managing styes is the focus of various ongoing investigations.

Topical and systemic antibiotics

Topical and systemic antibiotics have shown promise in managing styes, with a study published in Ophthalmology demonstrating the effectiveness of topical erythromycin or bacitracin ointment in preventing secondary infections. Research continues to focus on developing new antibiotic formulations to improve treatment outcomes while minimizing side effects, particularly for patients experiencing recurrent styes.[67]

Warm compresses and conservative measures

Warm compresses and conservative measures remain a 1st-line approach for treating mild cases. Clinical guidelines, including those from the American Academy of Ophthalmology, emphasize their role in treating styes without the need for surgery. Studies indicate that conservative measures successfully manage over 70% of cases within 1 to 2 weeks.[68]

Intralesional steroid injections

Intralesional steroid injections, particularly with triamcinolone, have been shown in studies to effectively treat chalazia or chronic stye cases that do not respond to other treatments. The success rate for steroid injections is approximately 77%, and the procedure is associated with minimal recurrence.[69]

Incision and drainage

Surgical management, specifically incision and drainage, has proven effective for larger styes or abscesses that do not respond to conservative measures. Data indicate that surgical resolution rates exceed 90%, and complications are minimal when the procedure is conducted by experienced practitioners.[70]

Studies on addressing underlying conditions and preventive care

Treating underlying conditions, such as rosacea and meibomian gland dysfunction, has been supported by trials that demonstrate the benefits of long-term use of low-dose doxycycline or ω3 supplementation to reduce stye recurrence in patients with these associated conditions.[71] Preventive care studies emphasize the importance of maintaining proper lid hygiene to prevent stye recurrence, with findings supporting the use of commercial lid scrubs or diluted baby shampoo as effective measures.[72]

Future Directions

For recurrent styes, ongoing studies are exploring the role of innovative modalities, such as laser-based heat therapies, in treating meibomian gland dysfunction, a common predisposing factor. For antibiotic stewardship, trials examine optimal antibiotic use to minimize resistance while maintaining efficacy in managing secondary infections.[73]

Conclusion

Although radiation therapy is not relevant to stye management, the evidence from existing studies underscores the importance of conservative measures, targeted antibiotics, and minor surgical interventions for effective resolution and recurrence prevention. These findings support current clinical guidelines for managing styes.

Treatment Planning

Treating Styes Based on Severity

Treatment planning for a stye does not involve radiation therapy as it is an external eye condition caused by an infection or blockage of the sebaceous glands. However, the treatment plan may be structured into stages and tailored according to the severity of the condition.

Mild cases

Mild styes require only conservative treatment, including warm compresses applied 3 to 4 times daily for 10 to 15 minutes to promote gland drainage and eyelid hygiene with diluted baby shampoo or lid scrubs to maintain cleanliness. If a secondary infection is suspected, topical antibiotics such as erythromycin and bacitracin ointment may be applied to the lid margin 2 to 4 times daily for 1 to 2 weeks. Artificial tears may be used to relieve dryness or discomfort. Treatment should focus on the affected eyelid, avoiding unnecessary medication use in the unaffected eye.

Moderate cases

Moderate cases, including persistent or larger lesions, usually require additional treatment beyond conservative measures. Oral antibiotics, such as doxycycline 100 mg daily for 7 to 10 days, are indicated if preseptal cellulitis is present or if the lesion fails to resolve, particularly in cases involving meibomian gland dysfunction or rosacea. Intralesional steroids may be considered for chalazia that do not respond to conservative approaches. Referral to an ophthalmologist for assessment and potential drainage is recommended if no improvement is seen after 1 to 2 weeks. Imaging, though rarely needed, may be employed to rule out deeper tissue involvement, such as orbital cellulitis, if complications arise.[74]

Severe cases

Severe cases, particularly complicated styes, require more intensive management. Systemic antibiotics, such as amoxicillin-clavulanate 500 mg orally twice daily for 10 to 14 days, are used for suspected cellulitis or recurrent infections. Surgical incision and drainage are indicated for large abscesses or chronic lesions unresponsive to conservative treatment. The abscess should be properly localized before incision and drainage to minimize complications and scarring.

Treatment Planning

Patients should be advised to follow up weekly for progress monitoring until the lesion resolves. Preventive measures include addressing underlying risk factors, such as blepharitis and rosacea, through long-term lid hygiene practices or maintenance antibiotics such as low-dose doxycycline.

Treatment planning for styes is interprofessional, involving primary care providers, ophthalmologists, and occasionally dermatologists. Management should focus on personalized and staged care to optimize outcomes.[75]

Toxicity and Adverse Effect Management

Potential Adverse Effects of Treatments

Understanding the potential adverse effects of stye treatments is crucial for ensuring patient safety and effective management. Besides symptom resolution, patients on follow-up must be assessed for the occurrence of complications while receiving therapy for hordeola.

• Topical antibiotics: Adverse effects of these agents include allergic reactions, contact dermatitis, and ocular irritation due to preservatives like benzalkonium chloride. Management includes switching to preservative-free formulations or alternative antibiotics and monitoring for worsening symptoms or hypersensitivity.[76]
• Systemic antibiotics: These drugs may lead to gastrointestinal upset, allergic reactions, or antibiotic resistance. Patients should be educated on completing the full course of treatment. Probiotic supplementation may be considered for gastrointestinal side effects. Switching to a different class of antibiotics is advised if hypersensitivity occurs.[77]
• Corticosteroids: Prolonged use of corticosteroids, such as when they are combined with antibiotics or used for chalazion management, can lead to increased intraocular pressure, cataract formation, or delayed wound healing. These drugs should be used only short-term and under close supervision by an ophthalmologist, with regular monitoring of intraocular pressure if extended use is necessary.[78]
• Incision and drainage: Incision and drainage can result in pain, infection, scarring, or incomplete resolution of the stye. A sterile technique must be ensured during the procedure to manage these risks. Postprocedure care instructions must be provided, including the use of antibiotic ointments and follow-up appointments to monitor healing.[79]

Toxicity Considerations

Overuse of antibiotics can lead to antimicrobial resistance, making future infections more difficult to treat. Consequently, clinicians must avoid prescribing antibiotics unnecessarily for uncomplicated styes. Meanwhile, the long-term use of preserved ointments or drops can irritate the ocular surface, so switching to preservative-free formulations is recommended if irritation occurs.[80]

Patient Education

The following measures can help minimize patient risks during treatment:

• Teach the proper application of medications to avoid contamination.
• Instruct patients to avoid self-manipulating the lesion, which can increase the risk of secondary infection.
• Reinforce adherence to prescribed regimens to ensure effective treatment and prevent complications.

By proactively addressing and managing potential adverse effects, healthcare providers can ensure safe and effective treatment of styes while minimizing risks to the patient.[81]

Staging

While hordeola are not traditionally staged in a formal classification system, the condition's progression may be understood in terms of clinical presentation and severity. Below is an informal staging system based on the progression of the disease.

• Early or initial stage (Stage 1): Early disease is characterized by mild localized redness, tenderness, and swelling along the eyelid margin. This stage arises from blockage and infection of the sebaceous glands (Zeis or meibomian glands) or hair follicles. Management typically includes warm compresses, lid hygiene, and observation, which are often sufficient for resolution.
• Progression or inflammatory stage (Stage 2): This stage is marked by increased redness and swelling, along with the formation of a small, tender, pus-filled nodule. Associated symptoms may include tearing, irritation, or mild pain. The inflammatory stage involves worsening inflammation and abscess formation within the infected gland. Management requires continuing with warm compresses. Topical antibiotics may be considered if the condition becomes severe or unresponsive.
• Advanced or complicated stage (Stage 3): The advanced stage presents with significant eyelid swelling and tenderness, as well as a persistent or enlarging lesion that may indicate secondary complications, such as preseptal cellulitis. This stage can lead to visual obstruction or discomfort due to mechanical ptosis. The pathophysiology involves chronic infection, abscess rupture, or deeper tissue involvement. Management may include incision and drainage along with systemic antibiotics if the infection spreads.[82]
• Resolution or chronic phase (Stage 4): The resolution or chronic phase is marked by a decrease in pain, swelling, and redness as the stye resolves. A chalazion may form in some cases. The pathophysiology in this stage involves the resolution of infection, potentially leading to scarring or gland dysfunction. For chalazion, management may include steroid injections or surgical removal if the nodule persists.

While not formally staged, understanding the progression can guide treatment strategies and anticipate complications. Early intervention during stage 1 or 2 typically prevents progression to more severe stages. Clinicians can tailor their management approach to optimize outcomes and minimize complications by categorizing stye progression.[83]

Prognosis

The prognosis for a stye is generally excellent with appropriate management. Most cases resolve spontaneously or require only conservative treatment and do not produce significant complications.

Short-term prognosis for styes varies depending on severity. Most uncomplicated styes resolve within 1 to 2 weeks with warm compresses and proper eyelid hygiene, and mild cases may not require additional medical treatment.[84] However, persistent or large styes may necessitate incision and drainage or topical antibiotics for resolution, with prompt treatment generally leading to favorable outcomes.

To determine long-term prognosis, recurrence risk and potential complications must be considered. Patients with underlying conditions such as blepharitis, meibomian gland dysfunction, or rosacea face a higher risk of hordeolum recurrence, making long-term management strategies like lid hygiene and dietary changes (eg, ω3 fatty acids) crucial for prevention. While rare, unresolved styes can lead to complications such as chalazion formation or secondary infections like preseptal cellulitis or orbital cellulitis, which early treatment can help minimize. Chronic or recurrent cases may sometimes result in cosmetic concerns or eyelid scarring, which are typically managed with surgical correction.

Key factors influencing prognosis include the following:

• Timeliness of treatment: Early intervention with conservative measures significantly improves outcomes and prevents complications.
• Patient compliance: Adherence to hygiene practices, warm compresses, and follow-up care ensures better resolution rates and fewer recurrences.
• Underlying conditions: Proper management of systemic or eyelid-related factors, such as diabetes or chronic blepharitis, enhances the overall prognosis.

In summary, most patients fully recover without any lasting effects with appropriate care. Long-term outcomes depend on addressing acute issues and predisposing factors to prevent recurrence.

Complications

Complications that may arise from a hordeolum include the following:

• Chalazion formation: If a stye does not resolve completely, it may evolve into a chalazion, a chronic, nontender nodule resulting from blocked meibomian glands. Chalazia often require surgical intervention for resolution.[85]
• Preseptal cellulitis: The spread of infection to the surrounding soft tissues of the eyelid can lead to preseptal cellulitis, a condition characterized by redness, swelling, and tenderness of the eyelid. This condition requires systemic antibiotics to prevent progression.[86]
• Orbital cellulitis: Rarely, untreated or severe infections can extend beyond the orbital septum, leading to orbital cellulitis, a potentially life-threatening condition requiring immediate hospitalization, intravenous antibiotics, and possibly surgical drainage.[87]
• Recurrent styes: Recurrences may occur due to underlying conditions such as blepharitis, meibomian gland dysfunction, or systemic conditions like diabetes mellitus. Frequent episodes can lead to patient frustration and a need for long-term management.
• Corneal involvement: Prolonged eyelid inflammation can irritate the cornea, causing keratitis or corneal abrasions, which may impair vision and require additional treatment.[88]
• Scarring and cosmetic concerns: Multiple recurrences or improperly managed infections can cause eyelid scarring or deformities, which can impact the patient’s appearance and require surgical correction.[89]

Prompt treatment with warm compresses and lid hygiene can prevent escalation. Close monitoring and early medical or surgical intervention for persistent or worsening cases can reduce the risk of severe complications. Addressing underlying conditions (eg, blepharitis, diabetes) and lifestyle factors (eg, makeup hygiene and contact lens use) is essential for minimizing recurrences. By recognizing and managing complications early, healthcare providers can improve outcomes and prevent more serious consequences associated with styes.