Hordeolum and Chalazion

11/18/2018 Hordeolum and chalazion- ClinicalKey
CLINICAL OVERVIEW
Hordeolum and chalazion

Elsevier Point of Care (see details)
Updated November 7, 2018. Copyright Elsevier BV. All rights reserved.
Synopsis
Key Points
A hordeolum is an infection of the eyelid margin typically caused by Staphylococcus species and is
one of the most common diseases affecting the eye
External hordeolum (also called stye) results from infection of a hair follicle or the glands of Zeis or
Moll and presents as tender pustule at the eyelid margin
Internal hordeolum results from obstruction and infection of a meibomian gland and causes
swelling and erythema of the entire eyelid. The lesion is visible on the tarsal conjunctiva when the
lid is everted
A chalazion is a sterile lipogranulomatous inflammation of the eyelid resulting from obstruction of a

meibomian gland and presents as an immobile, firm, nontender nodule close to eyelid margin
Initial treatment of both internal and external hordeolum and chalazion consists of measures
intended to promote drainage such as warm compresses and gentle lid massage
Severe or refractory hordeola may require topical or systemic antibiotics 1 or surgical incision and
drainage 2
Chalazia that do not resolve with conservative treatment may require intralesional steroid injection or
surgical excision
Pitfalls
Avoid antibiotic therapy for chalazia as topical and oral antibiotics offer no benefit
Consider sebaceous cell carcinoma as alternative diagnosis in cases of recurrent or persistent

chalazion 3
Excision and histopathologic analysis of chalazion specimen is recommended in cases not

responding to therapy and for patients with atypical symptoms, recurrence, older age, and lymph
node involvement; refer patient to an ophthalmologist
https://www.clinicalkey.com/#!/content/clinical_overview/67-s2.0-72c0bc91-298c-4ad0-a377-6c3374bd2078 1/13
Terminology
Clinical Clarification
Hordeolum and chalazion are common inflammatory eyelid disorders 4
Hordeolum (stye) is an infection of the external eyelid margin or tarsus typically caused by
Staphylococcus species 1 5
Chalazion is a sterile lipogranulomatous inflammation of sebaceous glands of the eyelid 6
Classification
Hordeola may be external or internal
External hordeolum (common stye) results from infection of a hair follicle 6 or glands of Zeis or
Moll at the eyelid margin 1
Internal hordeolum (meibomian stye) results from obstruction and infection of meibomian gland
on the tarsal conjunctiva 1
Both hordeola and chalazia may be acute, subacute, chronic, or recurrent
Hordeola are generally acute
Chalazia tend to be subacute or chronic
Recurrent hordeolum typically represents failure to fully resolve infection rather than new infection
1
Diagnosis
Clinical Presentation
History
Hordeolum presents as a painful, erythematous, focal

swelling of upper or lower eyelid margin 1
Develops rapidly and may be very tender
Internal hordeola are often more painful than external

hordeola 1 and may present with more diffuse swelling
Internal hordeolum. - Note the acute
and erythema of the entire eyelid 7 focal swelling and erythema of the lower
eyelid with obstruction of meibomian
External hordeola often come to a yellowish central point
gland orifice behind lash line.
on the outer eyelid
Degree of swelling is often a direct indicator of infection

severity
Chalazion presents as a painless localized nodule in the

eyelid 7
May begin as generalized swelling of the eyelid, which

evolves into a firm nodular lesion; may be slightly tender
Nodule typically grows slowly, with size varying from day External hordeolum and chalazion. - A,
to day Upper eyelid: external view of
chalazion. Note the focal swelling in the
Large chalazion may cause blurry vision due to pressure upper eyelid without significant
on the globe erythema. Lower eyelid: external
hordeolum with acute inflammation.
Very large lesion may become painful as it distends
sensory nerve endings
Patients with hordeola or chalazia may report a history of

hordeola or similarly presenting nodules
Hordeola and chalazia usually occur without any known

precipitating event; however, poor lid hygiene, systemic
infections, or certain skin conditions may predispose to their
development
Chalazion. - B, Inner palpebral view of
chalazion.
Physical examination
Hordeolum presents as a tender furuncle, 1 pustule, or inflammatory papule; yellowish exudate

may be visible 7
External hordeola infection comes to a point on the lid margin; may drain spontaneously 7
Internal hordeolum infection comes to a point on the conjunctival surface (in cases of meibomian
gland obstruction) or the lid margin (in cases of unobstructed meibomian gland) 7
Often associated with diffuse swelling and erythema of the entire eyelid 5
Eversion of the eyelid will demonstrate the lesion on the tarsal conjunctiva 7
Contents are purulent if expressed
Chalazia present as immobile firm nodules close to lid margin; most commonly involve upper eyelid
5 7
Overlying skin may appear normal or indurated
Ranges from 3 to 10 mm
Nontender or mildly tender
Mechanical ptosis may be evident in cases of large chalazia
Causes and Risk Factors

Causes
Hordeola are caused by infection, primarily with Staphylococcus aureus
External hordeola are caused by infection of the eyelash follicles or glands of Zeis or Moll 1
Internal hordeola are caused by infection of the meibomian glands 1
Chalazia are caused by obstruction and chronic lipogranulomatous inflammation of the meibomian
gland 8
Usually develops in context of inflammation due to blepharitis, rosacea, or chronic hordeolum
Risk factors and/or associations
Other risk factors/associations
Risk factors associated with hordeola
Diabetes 9
Blepharitis 9
Seborrheic dermatitis 9
Rosacea 9
Hyperlipidemia 9
Poor eyelid hygiene 1
Nasal carriage of staphylococci 1
Trichiasis 1
Cicatricial ectropion 1
Risk factors associated with chalazia 5
Blepharitis
Rosacea
Seborrheic dermatitis
Diagnostic Procedures
Primary diagnostic tools
Diagnosis of hordeolum and chalazion is based on clinical findings
Differential Diagnosis
Most common
Preseptal (periorbital)
Infection of the skin and soft tissue of the eyelid
cellulitis 10
Presents with edema and redness of the eyelid that may be
mistaken for a chalazion or internal hordeolum
Preseptal cellulitis is associated with more diffuse redness and

swelling and may be accompanied by mild fever
Differentiated based on clinical findings
Dacryocystitis 11
Inflammation and infection of the nasolacrimal sac, often
resulting in obstruction of the nasolacrimal duct
May resemble the clinical appearance of hordeolum and chalazion

with tender, erythematous, and edematous eyelid; however,
dacryocystitis involves the medial canthus overlying the lacrimal
space
Differentiated based on clinical findings
Sebaceous cell carcinoma 3

Invasive malignant cancer of the eyelid
Presents as a persistent small firm eyelid nodule that may be

mistaken for recurrent or refractory chalazion
Differentiated based on histopathologic analysis of the excised

nodule specimen
Treatment
Goals
Relieve symptoms and prevent complications
Disposition
Recommendations for specialist referral
Refer patients with the following diagnoses to an ophthalmologist:
Recurrent chalazia (to evaluate for malignancy) 4
Hordeola and chalazia that do not improve with conservative treatment or that interfere with
vision 8
Chalazia localized near the lacrimal punctum requiring surgical drainage 2
Treatment Options
Initial treatment of acute internal and external hordeolum and chalazion consists of measures
intended to promote drainage
Apply warm compress for 5 to 10 minutes several times daily to facilitate spontaneous drainage by
softening the granuloma 4
Gently massage affected area with lid scrub or mild shampoo (dilute baby shampoo to half-strength
with water) to promote lid hygiene, prevent spread of infection (for hordeola), and clear debris from
lid margin 1
For cases of external hordeola, pull out affected eyelash to promote drainage 1
Additional treatment options vary by condition
External hordeolum
Most resolve spontaneously within 1 to 2 weeks 1
Topical antibiotics (eg, bacitracin, erythromycin) given during the acute phase may help prevent
infection from spreading and promote healing 5
Systemic antibiotics are indicated only if associated with preseptal cellulitis 5
Refractory lesions may be incised and drained 5
Internal hordeolum
Severe or refractory cases may be treated with systemic antibiotics; usually, topical antibiotics are
ineffective 5
Systemic antibiotics (ie, doxycycline, dicloxacillin, erythromycin, cephalexin) are indicated if

topical antibiotics are unsuccessful or if infection is not localized (ie, if condition presents with
preseptal cellulitis or tender preauricular lymph nodes) 1
Incision and drainage may be indicated for cases unresponsive to less invasive treatments, those
with significant accumulation of pus, and those associated with preseptal cellulitis 2
Chalazion
Intralesional steroid injections are indicated for chalazion unresponsive to conservative

treatment and may be preferred to surgical incision, particularly for children and adults who may
not cooperate with the more complicated surgical procedure 12 13
Surgical excision of affected meibomian gland is indicated for chalazia that are unresponsive to
less invasive treatments, that represent a cosmetic deformity, and that cause vision problems 2
Topical or systemic antibiotics are ineffective
Drug therapy
Antibiotics
Topical antibiotics
Erythromycin 5
Erythromycin Ophthalmic ointment; Adults, Adolescents, Children, and Infants: Apply a

ribbon approximately 1 cm in length to the infected structure of the eye up to 6 times daily,
depending on severity of infection.
Bacitracin 5
Bacitracin Ophthalmic ointment; Adults, Adolescents, and Children: Apply a thin film to the
conjunctiva of the affected eye(s) 4 times daily during the acute phase and twice weekly for 1
additional week.
Sulfacetamide 14
Sulfacetamide Sodium Ophthalmic drops, solution; Adults, Adolescents, Children, and

Infants > 2 months: 1—2 drops to the affected eye(s) every 1—3 hours during the day, less
frequently at night.
Systemic antibiotics
Erythromycin (oral) 15
Erythromycin Oral tablet; Infants, Children, and Adolescents: 30 to 50 mg/kg/day (Max: 2

g/day) PO in 3 to 4 divided doses.
Erythromycin Oral tablet; Adults: 250 to 500 mg (base, estolate, or stearate) PO every 6
hours, or 400 to 800 mg (ethylsuccinate) PO every 6 hours.
Dicloxacillin 5
Dicloxacillin Sodium Oral capsule; Infants, Children, and Adolescents weighing < 40 kg: 12.5
to 25 mg/kg/day PO in equally divided doses q6h for mild/moderate infections; 25 to 50
mg/kg/day PO in equally divided doses q6h for severe infections.
Dicloxacillin Sodium Oral capsule; Adults, Adolescents, and Children weighing >= 40 kg: 125
to 250 mg PO q6h for mild/moderate infections; 250 to 500 mg PO q6h for severe infections.
Max 4 g/day PO.
Cephalexin 14
Cephalexin Monohydrate Oral suspension; Infants†, Children, and Adolescents: 25 to 50

mg/kg/day PO in 2 to 4 divided doses (Max: 2 g/day) for 7 to 14 days.
Cephalexin Monohydrate Oral tablet; Adults: 1 to 4 g daily, divided in 2 to 4 equal doses and
generally 250 mg PO every 6 hours or 500 mg PO every 12 hours; higher doses for severe
infections. Max: 4 g/day. Generally treat 7 to 14 days. Guidelines recommend 500 mg PO
every 6 hours for methicillin-susceptible Staphylococcal aureus (MSSA) or streptococcal
infections and 250 mg PO every 6 hours for 7 days impetigo or ecthyma.
Nondrug and supportive care
Initial treatment of acute internal and external hordeolum and chalazion consists of measures
intended to promote drainage
Apply warm compress for 5 to 10 minutes several times daily to facilitate spontaneous drainage
by softening the granuloma 4
Gently massage affected area with lid scrub or mild shampoo (dilute baby shampoo to half-
strength with water) to promote lid hygiene, prevent spread of infection (for hordeola), and clear
debris from lid margin 1
For cases of external hordeola, pull out affected eyelash to promote drainage 1
Procedures
Intralesional steroid injection
General explanation
Injection of 0.2 to 0.4 mL of a 40-mg/mL solution of triamcinolone acetonide through the

conjunctival surface of the eyelid using topical anesthesia 2
Indication
Chalazion that fails to resolve with conservative treatment 2
Contraindications
Hordeolum 12
Complications
Hypopigmentation, particularly in dark-skinned individuals 2
Yellow deposits at injection site 12
Elevated intraocular pressure 12
Globe perforation 12
Traumatic cataract 12
Microembolization 12
Retinal or choroidal vascular occlusions 12
Surgical incision and drainage of hordeolum 2
General explanation
Incision is made into hordeolum with a sterile needle or blade and pus is expressed 5
Indication 2
Hordeolum is unresponsive to other treatments
Hordeolum has significant accumulation of pus or is associated with preseptal cellulitis
Contraindications 2
Hordeolum located near the lacrimal punctum, owing to risk of damage
Complications
Disruption of lash growth
Eyelid scarring or malposition
Surgical excision of chalazion
General explanation
Incision is made into affected meibomian gland and granulomatous material of chalazion is
scraped out with a curette 5
Histopathologic analysis of specimen is recommended in cases not responding to therapy

and for patients with atypical symptoms, recurrence, older age, and lymph node involvement
3
Indication 2
Chalazion is unresponsive to other treatments
Chalazion is causing vision or problems or representing cosmetic deformities
Contraindications
Chalazion near the lacrimal punctum, owing to risk of damage
Complications 5
Subconjunctival hemorrhage
Eyelid scarring or malposition, or disruption of eyelash growth
Recurrent chalazion
Complications and Prognosis

Complications
Larger chalazia may irritate the conjunctiva 16 and can induce corneal astigmatism and mechanical
ptosis, leading to vision problems 17
Granulation of the tarsal plate may result from a ruptured chalazion 16
Hordeolum infection can spread, causing acute preseptal cellulitis or conjunctivitis 1
Pyogenic granuloma may form over chalazion 5
Prognosis
Both external and internal hordeola typically drain spontaneously within 1 to 2 weeks without
treatment; however, recurrence is common 1
Chalazia typically persist for longer than 2 weeks 7 but may resolve spontaneously within 6 months in
25% cases; most require treatment 5
Intralesional steroid injections and surgical therapy are highly effective in treating persistent chalazia
12
Screening and Prevention

Prevention
Individuals with recurrent hordeola or chalazia should use a warm cloth and diluted baby shampoo to
wash the eyelid margins and lashes regularly 18
REFERENCES
1: Lindsley K et al: Non-surgical interventions for acute internal hordeolum. Cochrane Database Syst
Rev. 1:CD007742, 2017
| Cross Reference (https://www.ncbi.nlm.nih.gov/pubmed/28068454)
2: Jackson JL: Chalazion and hordeolum. In: Pfenninger JL et al, eds: Pfenninger and Fowler's
Procedures for Primary Care. 3rd ed. Philadelphia, PA: Elsevier; 2011:427-32
3: Ozdal PC et al: Accuracy of the clinical diagnosis of chalazion. Eye (Lond). 18(2):135-8, 2004
4: Mueller JB et al: Ocular infection and inflammation. Emerg Med Clin North Am. 26(1):57-72, vi,
2008
5: Skorin L Jr: Hordeolum and chalazion treatment: the full gamut. Optometry Today. June 28, 2002.
Accessed June 20, 2018.
https://pedclerk.bsd.uchicago.edu/sites/pedclerk.uchicago.edu/files/uploads/Treatment.pdf
| Cross Reference (https://pedclerk.bsd.uchicago.edu/sites/pedclerk.uchicago.edu/files/uploads/Treatment.pdf)
6: Deibel JP et al: Ocular inflammation and infection. Emerg Med Clin North Am. 31(2):387-97, 2013
7: Wald ER: Periorbital and orbital infections. Infect Dis Clin North Am. 21(2):393-408, vi, 2007
8: McAlinden C et al: Hordeolum: acute abscess within an eyelid sebaceous gland. Cleve Clin J Med.
83(5):332-4, 2016
9: Bragg KJ et al: Hordeolum. StatPearls. NCBI Bookshelf. Updated October 10, 2017. Accessed June
29, 2018. https://www.ncbi.nlm.nih.gov/books/NBK441985/
| Cross Reference (https://www.ncbi.nlm.nih.gov/books/NBK441985/)
10: Carlisle RT et al: Differential diagnosis of the swollen red eyelid. Am Fam Physician. 92(2):106-12,
2015
11: Taylor RS et al: Dacryocystitis. StatPearls. NCBI Bookshelf. Updated December 3, 2017. Accessed
June 22, 2018. https://www.ncbi.nlm.nih.gov/books/NBK470565/
| Cross Reference (https://www.ncbi.nlm.nih.gov/books/NBK470565/)
12: Lee JW et al: A comparison of intralesional triamcinolone acetonide injection for primary chalazion
in children and adults. ScientificWorldJournal. 2014:413729, 2014
13: Ben Simon GJ et al: Intralesional triamcinolone acetonide injection versus incision and curettage for
primary chalazia: a prospective, randomized study. Am J Ophthalmol. 151(4):714-718.e1, 2011
14: Bartlett JG et al, eds: Johns Hopkins ABX guide: diagnosis and treatment of infectious diseases. 3rd
ed. Burlington, MA: Jones & Bartlett Learning; 2012
15: Buttaravoli P et al: Hordeolum: (stye). In: Buttaravoli P et al, eds: Minor Emergencies. Philadelphia,
PA: Elsevier; 2012:79-80
16: Peralejo B et al: Dermatologic and allergic conditions of the eyelid. Immunol Allergy Clin North Am.
28(1):137-68, vii, 2008
17: Ben Simon GJ et al: Intralesional triamcinolone acetonide injection for primary and recurrent
chalazia: is it really effective? Ophthalmology. 112(5):913-7, 2005
18: Lederman C et al: Hordeola and chalazia. Pediatr Rev. 20(8):283-4, 1999
Copyright © 2018 Elsevier, Inc. All rights reserved.

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11/18/2018 Hordeolum and chalazion- ClinicalKey

Hordeolum and chalazion

A chalazion is a sterile lipogranulomatous inflammation of the eyelid resulting from obstruction of a

Consider sebaceous cell carcinoma as alternative diagnosis in cases of recurrent or persistent

Excision and histopathologic analysis of chalazion specimen is recommended in cases not

Chalazion is a sterile lipogranulomatous inflammation of sebaceous glands of the eyelid 6

Both hordeola and chalazia may be acute, subacute, chronic, or recurrent

Hordeola are generally acute

Chalazia tend to be subacute or chronic

Hordeolum presents as a painful, erythematous, focal

Develops rapidly and may be very tender

Internal hordeola are often more painful than external

Degree of swelling is often a direct indicator of infection

Chalazion presents as a painless localized nodule in the

May begin as generalized swelling of the eyelid, which

Patients with hordeola or chalazia may report a history of

Hordeola and chalazia usually occur without any known

Hordeolum presents as a tender furuncle, 1 pustule, or inflammatory papule; yellowish exudate

Contents are purulent if expressed

Overlying skin may appear normal or indurated

Nontender or mildly tender

Mechanical ptosis may be evident in cases of large chalazia

Causes and Risk Factors

Hordeola are caused by infection, primarily with Staphylococcus aureus

Internal hordeola are caused by infection of the meibomian glands 1

Usually develops in context of inflammation due to blepharitis, rosacea, or chronic hordeolum

Risk factors and/or associations

Other risk factors/associations

Risk factors associated with hordeola

Poor eyelid hygiene 1

Nasal carriage of staphylococci 1

Risk factors associated with chalazia 5

Diagnosis of hordeolum and chalazion is based on clinical findings

Preseptal cellulitis is associated with more diffuse redness and

Differentiated based on clinical findings

May resemble the clinical appearance of hordeolum and chalazion

Differentiated based on clinical findings

Sebaceous cell carcinoma 3

Presents as a persistent small firm eyelid nodule that may be

Differentiated based on histopathologic analysis of the excised

Relieve symptoms and prevent complications

Refer patients with the following diagnoses to an ophthalmologist:

Recurrent chalazia (to evaluate for malignancy) 4

Chalazia localized near the lacrimal punctum requiring surgical drainage 2

Additional treatment options vary by condition

Most resolve spontaneously within 1 to 2 weeks 1

Systemic antibiotics are indicated only if associated with preseptal cellulitis 5

Refractory lesions may be incised and drained 5

Systemic antibiotics (ie, doxycycline, dicloxacillin, erythromycin, cephalexin) are indicated if

Intralesional steroid injections are indicated for chalazion unresponsive to conservative

Topical or systemic antibiotics are ineffective

Erythromycin Ophthalmic ointment; Adults, Adolescents, Children, and Infants: Apply a

Sulfacetamide Sodium Ophthalmic drops, solution; Adults, Adolescents, Children, and

Erythromycin Oral tablet; Infants, Children, and Adolescents: 30 to 50 mg/kg/day (Max: 2

Cephalexin Monohydrate Oral suspension; Infants†, Children, and Adolescents: 25 to 50

Nondrug and supportive care

Intralesional steroid injection

Injection of 0.2 to 0.4 mL of a 40-mg/mL solution of triamcinolone acetonide through the

Chalazion that fails to resolve with conservative treatment 2

Hypopigmentation, particularly in dark-skinned individuals 2

Yellow deposits at injection site 12

Elevated intraocular pressure 12

Retinal or choroidal vascular occlusions 12

Surgical incision and drainage of hordeolum 2