Author(s): Jill C.Cash and Mellisa A.Hall
Definition
- Hordeolum is an infection of the glands of the eyelids (follicle of an eyelash or the associated gland of Zeis [sebaceous] or Molls gland [apocrine sweat gland]), usually caused by Staphylococcus aureus.
- If swelling is under conjunctival side of eyelid, it is an internal hordeolum.
- If swelling is under the skin of the eyelid, it is an external hordeolum.
Incidence
- The incidence is unknown; it is more common in children and adolescents than in adults.
Pathogenesis
- Acute bacterial infection of the meibomian gland (internal hordeolum) or of the eyelash follicle (external hordeolum) is usually caused by S. aureus.
Predisposing Factors
- Age: Commonly seen in adults.
- Meibomian gland dysfunction.
- Rosacea.
Common Complaints
- Eye tenderness.
- Sudden onset of a purulent discharge.
- Painful bump on the edge of the eyelid.
Other Signs and Symptoms
- Redness and swelling of the eye.
Subjective Data
- Review the onset, course, and duration of symptoms.
- Determine whether there is any visual disturbance.
- Note whether this is the first occurrence. If not, ask how it was treated before.
- Evaluate how much pain or discomfort the patient is experiencing.
- Review the patients history for chemical, foreign body, and/or trauma etiology.
- Review the patients medical history and medications.
- Does the patient have a history of rosacea or frequent meibomian gland dysfunction?
Physical Examination
- Inspect:
- Examine both eyes; note redness, site of swelling, and amount and color of discharge.
- Evert the lid and check for pointing.
- Assess sclera and conjunctivae for abnormalities.
- Inspect ears, nose, and throat.
- Palpate:
- Palpate eye for hardness and expression of discharge.
- Evaluate for preauricular adenopathy.
Diagnostic Tests
- Test visual acuity.
- Discharge can be cultured but is usually treated presumptively.
Differential Diagnoses
- Hordeolum.
- Chalazion: The main differential diagnosis is chalazia, which point on the conjunctival side of the eyelid and do not usually affect the margin of the eyelid.
- Blepharitis.
- Xanthoma.
- Bacterial conjunctivitis.
- Foreign body.
- Basal cell carcinoma/sebaceous cell carcinoma.
Plan
- General interventions:
- Contain the infecting pathogen. Crops occur when the infectious agent spreads from one hair follicle to another.
- Patient teaching:
- See Section III: Patient Teaching Guide for How to Administer Eye Medications.
- Apply warm compresses to eye 10 to 15 minutes four times a day for comfort.
- Instruct on proper eyelid hygiene and good handwashing.
- Patients should discard all eye makeup, including mascara, eyeliner, and eye shadow.
- Pharmaceutical therapy:
- If hordeolum does not resolve with warm compresses within 5 days or if multiple sites infected:
- Erythromycin ophthalmic 0.5% ointment 1 cm to affected eye up to six times daily.
- If crops of sties occur, some clinicians recommend a course of tetracycline to stop recurrences (consult with a physician).
- If cellulitis of the surrounding tissue is suspected, oral antibiotics that cover Staphylococcus are recommended. Oral antibiotics recommended include cephalexin and erythromycin.
Follow-Up
- Have patient telephone or visit the office in 48 hours to check response.
- If crops occur, diabetes mellitus must be excluded. Perform blood glucose evaluation.
- Recommended follow-up appointment in 2 weeks.
Consultation/Referral
- Hordeolum may produce a diffuse superficial lid infection, preseptal cellulitis, requiring referral to an ophthalmologist.
- If hordeolum does not respond to topical antimicrobial treatment, refer the patient to an ophthalmologist for possible incision and drainage if indicated.
- Recurrent lesions should be referred to an ophthalmologist for further evaluation and treatment (biopsy) for possible basal cell carcinoma or sebaceous cell carcinoma.
Individual Considerations
- Adults:
- Recurrent lesions should be referred to a specialist for evaluation and workup for possible carcinoma.
- Hordeolums are benign infections and usually respond in 1 to 2 weeks with proper treatment. If lesion has not resolved, further workup is recommended.
- Geriatrics:
- Nonpharmacological treatments include warm compresses for 20 to 30 minutes (rewetting washcloth every 5–10 minutes), applying a gentle massage, discontinuing wearing contact lens and eye makeup until healed, and encouraging patients to keep hands clean and to not rub their eyes.
- Pharmacological treatment common for geriatrics: Short-term NSAIDs for pain and inflammation, and Tobradex® ointment three to four times a day for 1 week (combination of an antibiotic and anti-inflammatory).