Hordeolum (Stye) and Chalazion
Acute bacterial vs chronic granulomatous obstruction of eyelid sebaceous glands — warm compresses are mainstay.
Also known as: hordeolum, stye, external hordeolum, internal hordeolum, chalazion, meibomian cyst
Overview
Hordeolum is an acute, painful, suppurative infection of an eyelid sebaceous gland — external when arising from glands of Zeis or Moll along the lash line (classic stye), internal when arising from a meibomian gland in the tarsal plate. Chalazion is a chronic, sterile, granulomatous inflammation from a retained meibomian gland secretion — typically painless and rubbery.
Epidemiology
Common at all ages; peak incidence in adults 30-50. Recurrence is frequent, especially with rosacea or chronic blepharitis. Children with poor lid hygiene are also affected.
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Risk factors
- Chronic blepharitis or meibomian gland dysfunction
- Ocular rosacea, seborrheic dermatitis, atopic dermatitis
- Diabetes mellitus
- Poor eyelid hygiene; rubbing eyes; eye makeup that occludes lid margin
- Contact lens wear with inadequate hygiene
- Prior hordeolum or chalazion
Pathophysiology
Hordeolum: obstruction of a sebaceous gland leads to bacterial superinfection — usually Staphylococcus aureus — producing focal abscess. External hordeolum points anteriorly through the skin; internal hordeolum points through the conjunctival surface. Chalazion: lipogranulomatous reaction to meibomian gland secretions that have leaked into surrounding tarsal tissue after duct obstruction; no organism, no acute infection.
Clinical presentation
Symptoms
- Hordeolum: acute onset tender, red, warm eyelid bump over hours to days
- Foreign body sensation if lesion abrades cornea
- Mild tearing; usually no decrease in vision
- Chalazion: gradual painless lid nodule, often weeks; may follow a resolved hordeolum
Signs / physical exam
- External hordeolum: tender pustule along lash line, points externally
- Internal hordeolum: tender focal swelling on tarsal plate, points to conjunctival side on lid eversion
- Chalazion: firm, rubbery, NON-tender nodule within the tarsus; overlying skin normal
- Surrounding lid erythema or diffuse edema if secondary infection
- Look for blepharitis and meibomian gland dysfunction
Classic findings
Tender, well-localized lid pustule (hordeolum) vs painless rubbery tarsal nodule (chalazion).
Differential diagnosis
- Preseptal cellulitis — Diffuse lid erythema/edema without focal lesion, fever; oral antibiotics, exclude orbital involvement
- Orbital cellulitis — Proptosis, painful EOM, decreased vision, fever; CT orbits; IV antibiotics; surgical drainage if abscess
- Sebaceous gland carcinoma — Recurrent or persistent chalazion-like lesion in elderly, often upper lid; biopsy any chalazion that does not resolve or recurs in same site
- Basal cell carcinoma of lid margin — Pearly nodule with telangiectasias, lash loss; biopsy
- Pyogenic granuloma — Rapidly growing red friable papule, often following chalazion incision; excision
- Molluscum contagiosum of lid — Umbilicated dome-shaped papules; can cause follicular conjunctivitis
- Dacryocystitis — Tender swelling at medial canthus over lacrimal sac with mucopurulent reflux; systemic antibiotics
Diagnostic workup
Labs
- Clinical diagnosis — no labs routinely required
- Culture of expressed pus if recurrent, antibiotic failure, or atypical (MRSA suspicion)
- Biopsy any recurrent chalazion in the same location, especially in patients >50, to exclude sebaceous gland carcinoma
Imaging
- Imaging not indicated unless orbital cellulitis or atypical mass suspected (then CT orbits with contrast)
Diagnostic algorithm
| Feature | Hordeolum (Stye) | Chalazion |
|---|---|---|
| Onset | Acute (days) | Subacute to chronic (weeks) |
| Pain | Tender, warm | Painless |
| Etiology | Bacterial (S. aureus) | Sterile granulomatous reaction |
| Gland involved | Zeis/Moll (external) or meibomian (internal) | Meibomian |
| Location | Lash line or tarsal | Within tarsal plate |
| First-line treatment | Warm compresses, lid hygiene | Warm compresses, lid hygiene |
| Procedure | Rarely needed; I&D if abscess | I&D or intralesional steroid if >4-6 wk |
Treatment
First-line
- Warm compresses 10-15 minutes 4 times daily — mainstay of therapy for both hordeolum and chalazion
- Eyelid hygiene: gentle lid scrubs with diluted baby shampoo or commercial lid wipes
- Light digital massage of nodule after warm compress to promote drainage
- Avoid eye makeup and contact lenses until resolved
Second-line / adjunct
- Topical ocular antibiotic — erythromycin ointment, polymyxin/trimethoprim, or bacitracin ointment — applied to lid margin if drainage occurs or surrounding cellulitis; not needed for uncomplicated lesions
- Oral antibiotics — dicloxacillin, cephalexin, or doxycycline — for surrounding preseptal cellulitis, large abscess, or systemic symptoms; add MRSA coverage (trimethoprim-sulfamethoxazole, doxycycline, clindamycin) where prevalent
- Oral doxycycline 100 mg BID × 6-12 weeks or low-dose maintenance for recurrent chalazia with rosacea/MGD
- Incision and curettage from conjunctival surface by ophthalmology for chalazion persisting >4-6 weeks or causing astigmatism/ptosis
- Intralesional corticosteroid injection (triamcinolone 5-10 mg/mL) — alternative to I&D for small to moderate chalazia; risk of depigmentation in dark skin
- Ophthalmology referral for recurrent same-site lesions, persistent >6 weeks, lash loss, or suspicion of malignancy
Complications
- Preseptal or orbital cellulitis if secondary spread
- Cosmetic deformity, lid notching, lash loss after I&D
- Induced astigmatism from large chalazion pressing on cornea
- Recurrence — especially with untreated blepharitis or rosacea
- Missed sebaceous gland carcinoma in 'recurrent chalazion'
PANCE pearls
- Hordeolum is acute, painful, and bacterial; chalazion is chronic, painless, and granulomatous — they are NOT a spectrum, although a hordeolum can evolve into a chalazion after acute phase resolves.
- Warm compresses 4×/day is the highest-yield intervention; topical antibiotics add little for the typical uncomplicated stye.
- Never squeeze or incise externally — promotes scarring; if drainage is needed, transconjunctival I&D by ophthalmology.
- Any chalazion that recurs in the same location should be biopsied to exclude sebaceous gland carcinoma — the great masquerader of the eyelid.
- Treat underlying blepharitis, meibomian gland dysfunction, and ocular rosacea to prevent recurrence — long-term doxycycline is a recognized option.
References
- AAO 2018 — American Academy of Ophthalmology. Blepharitis Preferred Practice Pattern. Ophthalmology 2019;126(1):P56-P93
- AAO EyeWiki — American Academy of Ophthalmology. Hordeolum and Chalazion (EyeWiki, accessed 2026)
- Cochrane 2017 — Lindsley K et al. Interventions for acute internal hordeolum. Cochrane Database Syst Rev 2017;1:CD007742
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