This concise clinical article discusses how to evaluate and treat a stye, or hordeolum which is one of the most often encountered presenting symptoms in general OPDs and the role of the interprofessional team in treating patients with this ailment.

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Presentation of stye

A hordeolum or stye typically presents as a tiny pustule along the eyelid border and may be distinguished from a chalazion, which often involves less inflammation and has a more chronic history. Causative agents for this type of eye issue are as follows:

1. Hordeolum is an acute bacterial infection of the eyelid edge that is caused by Staphylococcus aureus.
2. The second most prevalent cause is staphylococcus epidermidis.
3. An external hordeolum is a localised abscess of the lash follicle.
4. An internal hordeolum is an acute bacterial infection of the eyelid's meibomian glands.
5. A chalazion is an acute or chronic inflammation of the eyelid caused by occlusion of the tarsal plate's oil glands (meibomian or Zeis) and foreign body response to sebum.
6. Hordeolum, acne, and blepharitis may all cause chalazia by preventing the sebaceous glands from draining properly.

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Prevalence and incidence

The actual occurrence of hordeola is unclear, despite the fact that they are quite frequent. Every age and the demographic group is affected, however, the prevalence is somewhat higher in people aged 30 to 50. Worldwide, there are no documented variations in prevalence. Patients with chronic diseases such as seborrheic dermatitis, diabetes, or elevated blood lipids may also be at an increased risk.

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Pathophysiological mechanisms

External hordeolum- When infected with S. aureus, three distinct glands inside the eyelid are involved in the aetiology of hordeolum. Infection of the Zeis and Moll glands (ciliary glands) results in discomfort and swelling near the base of the eyelash, as well as the creation of a localised abscess. These are referred to as external hordeolum and have the characteristic look of a stye with a localised pustule on the eyelid edge.

Internal hordeolum- Meibomian glands are specialised sebaceous glands located on the tarsal plate of the eyelids. They form an oily film on the surface of the eye, which aids in maintaining normal eye lubrication. When a meibomian gland is severely diseased, an internal hordeolum develops. Internal hordeola have a less distinct look than external hordeolum due to their deeper location inside the eyelid.

Chalazia- It developed as a result of mechanical obstruction and malfunction of the meibomian gland, resulting in sebum stasis and blockage. This illness is often subacute to chronic in nature and manifests as an asymptomatic nodule inside the eyelid or near the lid edge.

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Assessment

Patients often appear with a restricted burning, painful swelling on one eyelid. Upper or lower lid involvement is possible. In certain situations, the complaint may begin as widespread oedema and erythema of the lid that eventually becomes localised. Patients typically have a history of comparable previous eyelid lesions.

1. External hordeolum causes discomfort, oedema, and swelling to be limited to a distinct region of the eyelid that is palpably painful. The stye often presents as a pustule with modest lid border erythema. Exudate from pustules may be present.
2. Internal hordeolum patients exhibit more generalised discomfort and erythema of the lid since the meibomian gland is significantly bigger. Evert the lid to show a tiny pustule on the conjunctival surface. When the gland is diseased but not obstructed, the physical exam may seem quite similar to an external hordeolum.
3. Internal and external hordeolum are treated identically, and hence the distinction between the two is not clinically relevant.
4. Chalazion, unlike hordeola, is more indolent and persistent. Patients report non-tender nodules on their upper eyelids with little to no surrounding erythema. Chronic skin changes might develop around the underlying nodule in cases of persistent chalazion.

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How to evaluate

A stye (hordeolum) and chalazion are easily diagnosed with a history and physical examination. There are no diagnostic tests that are necessary or beneficial in their diagnosis. Colonisation by noninvasive bacteria is widespread, and bacterial cultures obtained from discharge from the region seldom correlate with clinical improvement or assist in therapy. Although the clinical picture of an acute chalazion and an internal hordeolum may be difficult to distinguish, luckily, treatment is the same.

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Therapeutic management

Treatment for internal and external hordeola

A stye is often a self-limiting ailment that resolves on its own within a week. Internal and external hordeola are treated in the same way.

1. Warm compresses and erythromycin ophthalmic ointment administered twice daily are typically adequate to speed healing and prevent infection spread. Although there is little evidence to support the use of topical antibiotics, erythromycin ointment for seven to ten days has been advised.
2. Warm compresses should be administered for 15 minutes four times a day at the very least. Additionally, gentle massaging of the nodule has been advised to aid in the release of the occluded material.
3. Oral antibiotics are seldom needed unless substantial erythema and risk of periorbital cellulitis are present.
4. Referral to an ophthalmologist is recommended for really extensive hordeola that need surgery and drainage.
5. Reevaluation within two to three days after treatment completion is recommended to determine responsiveness to therapy.

Treatment for chalazia

Conservative treatment is the cornerstone of chalazia therapy.

1. Generally, warm compresses and cleaning the affected eyelid with a mild soap such as baby shampoo would suffice. Antibiotics are not required since the aetiology is inflammatory rather than infectious.
2. Corticosteroid injection into the lesion or incision and curettage may be necessary for recurring chalazion or those that are resistant to conservative therapy.
3. Referral to an ophthalmologist is required for these operations.
4. Patients with chalazia should be referred for non-emergency examination to an ophthalmologist.

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Other close diagnoses

• Chalazion
• Basal cell carcinoma
• Preseptal cellulitis
• Squamous cell carcinoma
• Sebaceous gland carcinoma
• Pneumo-orbita

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Certain issues that should not be ignored

Cellulitis- Although it occurs very uncommonly, an untreated stye may evolve into localised cellulitis of the eyelid and surrounding skin. Periorbital, or rarely, orbital cellulitis, may ensue if the progression of the infection is allowed to occur. Any worsening erythema and oedema beyond a localised pustule should be monitored closely for cellulitis, which may require systemic antibiotics. For infections that are not well localised, blood tests including a complete blood count (CBC) with differential and blood cultures may be needed, in addition to an orbital CT scan if orbital cellulitis is a possibility.

Blepharitis- It is a related condition that involves inflammation of the eyelid margin characterised by erythematous, pruritic eyelids, conjunctival injection, crusting or matting of the eyelids, and occasionally flaking of the eyelid skin. In contradistinction to hordeolum and chalazion, blepharitis should not have a discrete nodule within the eyelid. Treatment involves warm compresses, gentle washing of the eyelids with warm water or diluted baby shampoo, and if these attempts are unsuccessful, a topical antibiotic such as erythromycin.

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Aiming for better results

While general healthcare practitioners can handle the majority of styes conservatively, if there is any uncertainty about the diagnosis, the patient should be sent to an ophthalmologist. Warm compresses and erythromycin ointment do have a quick effect on styes. The patient must, however, be examined again within 48 to 72 hours to establish that healing has occurred. The majority of people with stye have great results.

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Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

The author is a practising super specialist from New Delhi.