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Styes (hordeola)

602 words•Updated 03/03/2026
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Exam Tips

  • Differentiate external vs internal hordeolum anatomically: lash-line follicle/Zeis-Moll vs meibomian gland in tarsal plate.
  • Red flags in OSCEs: reduced vision, painful/restricted eye movements, proptosis, fever, severe headache, or systemically unwell patient -> same-day emergency assessment for orbital/periorbital cellulitis.
  • Recurrent lesion in the same site, especially in older adults, should trigger suspicion for sebaceous gland carcinoma and urgent ophthalmology pathway.
  • If lesion is painless and chronic, think chalazion rather than acute hordeolum.
  • Image aid: compare external lash-line pustule versus deep tarsal swelling on lid eversion (see Figure: external vs internal hordeolum in standard ophthalmology teaching atlases).

Definition

A stye (hordeolum) is an acute, localized inflammation/infection of an eyelid gland unit, most often due to Staphylococcus aureus. External hordeola arise from an eyelash follicle with Zeis or Moll gland involvement at the lid margin, while internal hordeola involve a meibomian gland within the tarsal plate and are typically deeper and more painful.

Pathophysiology

Obstruction of a sebaceous/apocrine gland outlet at the eyelid margin promotes stasis of secretions, then secondary bacterial overgrowth (classically staphylococcal) triggers an acute neutrophilic inflammatory response and small abscess formation. External lesions are superficial and point toward the skin at the lash line; internal lesions are deeper within the tarsal plate and may point posteriorly through conjunctiva. Persistent duct obstruction and chronic granulomatous inflammation can evolve into a chalazion (meibomian cyst).

Risk Factors

  • Poor eyelid hygiene
  • Chronic blepharitis
  • Acne rosacea
  • Diabetes or other causes of reduced immunity
  • Raised serum cholesterol (predisposes to meibomian/sebaceous blockage)
  • Local irritants and exacerbators (eye makeup, fragranced products, contact lens wear)

Clinical Features

Symptoms

  • Acute tender eyelid lump (usually unilateral)
  • Localized eyelid pain/soreness
  • Epiphora (watery eye)
  • Mild red eye or foreign-body irritation
  • Occasional bilateral episodes in recurrent disease

Signs

  • Focal erythematous, tender swelling at lid margin (external hordeolum)
  • Deeper, more painful lid swelling away from margin (internal hordeolum)
  • Localized pustular 'pointing' through skin or conjunctival surface
  • Associated lid-margin inflammation/blepharitis signs
  • Usually normal visual acuity and full eye movements (red flags if abnormal)

Investigations

Clinical diagnosis (history + eyelid examination):Typical acute tender localized lid swelling consistent with external or internal hordeolum
Visual acuity and ocular red-flag assessment:Usually preserved vision and no painful ophthalmoplegia/proptosis; abnormalities suggest alternative diagnosis or orbital involvement
Eyelid eversion (if internal lesion suspected):Localized tarsal/conjunctival swelling in meibomian gland region
Targeted tests only if recurrent/atypical:Consider glucose/HbA1c, lipid assessment, or specialist biopsy if malignancy or systemic risk factors are suspected

Management

Lifestyle Modifications

  • Warm compress to closed eyelid for 5-10 minutes, 2-4 times daily, with gentle lid hygiene
  • Stop eye makeup and avoid contact lenses until healed
  • Do not squeeze or puncture the lesion
  • Treat contributory conditions (for example blepharitis/rosacea control) to reduce recurrence
  • Urgent same-day escalation if red flags: visual loss, painful/restricted eye movements, proptosis, severe systemic upset, or rapidly worsening eyelid erythema/swelling

Pharmacological Treatment

Analgesia

  • Paracetamol 1 g orally every 4-6 hours when required (max 4 g/day in adults)
  • Ibuprofen 200-400 mg orally three times daily with food when required (max 1.2 g/day OTC-equivalent; higher only on clinical advice)

Use for pain only. Check contraindications: NSAIDs avoided/cautioned in peptic ulcer disease, significant renal impairment, NSAID-sensitive asthma, anticoagulation risk, and late pregnancy.

Topical ophthalmic antibiotic (only if secondary conjunctival discharge/mucopurulence)

  • Chloramphenicol 0.5% eye drops: 1 drop every 2 hours for 48 hours, then every 4 hours; continue for 5 days total
  • Chloramphenicol 1% eye ointment: apply 3-4 times daily (or at night with drops) for about 5 days

Antibiotics are not routine for uncomplicated styes. Avoid in chloramphenicol hypersensitivity; use caution with past blood dyscrasia/bone marrow suppression history. Reassess if not improving, and refer if cellulitis or atypical features develop.

Surgical / Interventional

  • Epilation of the involved eyelash (external stye) by trained clinician to aid drainage
  • Incision and drainage with sterile technique in primary care only where expertise/equipment exist; otherwise ophthalmology referral
  • Ophthalmology review for large, severe, atypical, or non-resolving lesions

Complications

  • Infective conjunctivitis
  • Progression to meibomian cyst (chalazion)
  • Eyelid cellulitis (preseptal/periorbital cellulitis)
  • Orbital cellulitis (rare, sight- and life-threatening emergency)
  • Recurrence, especially with persistent risk factors

Prognosis

Most styes are self-limiting and settle within about 5-7 days with conservative care. Recurrence is common if underlying lid disease (for example blepharitis/rosacea) or systemic risk factors are not addressed.

Sources & References

✅NICE Guidelines(1)

Sources

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