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