Hordeola present as painful, tender, red nodular masses near the eyelid margin (Fig 3-21). Those occurring on the anterior eyelid in the glands of Zeis or lash follicles are called external hordeola, or styes. Hordeola occurring on the posterior eyelid from meibomian gland inspissation are termed internal hordeola. Both types are associated with a localized purulent abscess, usually caused by S aureus, and may rupture, producing a purulent drainage. Hordeola are generally self-limited, improving spontaneously over the course of 1–2 weeks.
Figure 3-21 Hordeolum.
(Courtesy of Vincent P. deLuise, MD.)
Internal hordeola occasionally evolve into chalazia, which are chronic lipogranulomatous nodules involving either the meibomian glands or the glands of Zeis. The lesion disappears in weeks to months, when the sebaceous contents drain either externally through the eyelid skin or internally through the tarsus or when the extruded lipid is phagocytosed and the granuloma dissipates. A small amount of scar tissue may remain. Occasionally, patients with a chalazion experience blurred vision secondary to astigmatism induced by its pressure on the globe. Basal cell, squamous cell, and sebaceous cell carcinoma can masquerade as chalazia or chronic blepharitis. The histologic examination of persistent, recurrent, or atypical chalazia is therefore important. Lash loss occurring over a chronic lesion is suggestive of malignancy.
Cultures are not indicated for isolated, uncomplicated cases of hordeolum or chalazion. Warm compresses can facilitate drainage. Topically applied antibiotics are generally not effective and, therefore, are not indicated unless an accompanying infectious blepharoconjunctivitis is present. Systemic antibiotics are generally indicated only in cases of secondary eyelid cellulitis. If the patient has a prominent and chronic accompanying meibomitis, oral doxycycline may be necessary.
If an internal hordeolum evolves into a chalazion that fails to respond to warm compresses and eyelid hygiene, intralesional injection of a corticosteroid (eg, 0.1–0.2 mL of triamcinolone 40 mg/mL), incision and curettage, or both may be necessary. In general, intralesional corticosteroid injection works best with small chalazia, chalazia on the eyelid margin, and multiple chalazia. Intralesional corticosteroid injection in patients with dark skin may lead to depigmentation of the overlying eyelid skin and thus should be used with caution. Oral doxycycline can be helpful for a patient with recurrent chalazia.
Large chalazia are best treated with surgical drainage and curettage. Internal chalazia require vertical incisions through the tarsal conjunctiva along the meibomian gland to facilitate drainage and avoid horizontal scarring of the tarsal plates. Surgical drainage usually requires perilesional anesthesia. A biopsy should be performed for recurrent chalazia to rule out meibomian gland carcinoma.
See also BCSC Section 7, Oculofacial Plastic and Orbital Surgery, for further discussion of chalazion.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.