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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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
Hordeolum vs chalazion — distinguishing features and management.
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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