Infected Chalazion / Hordeolum: An Overview

Mohamed Baana

Definition

A hordeolum (or also stye) is an acute, localized bacterial infection of the sebaceous glands of the eyelid, either of the glands of Zeis (external hordeolum) or the meibomian glands (internal hordeolum) (1,2,3,4). The condition presents as a painful, localized purulent infection of the sebaceous glands of the eyelid of either gland of Zeis (external hordeolum) or the meibomian glands (internal hordeolum) (5,6). Conversely, an infected chalazion is a chronic, non-infectious, lipogranulomatous inflammatory lesion caused by ductal blockage of the meibomian gland, which changes an otherwise painless, firm lesion into an acute, painful lesion, which is tender, warm, and swollen, and which clinically simulates an internal hordeolum (7,8).

Causes and Risk Factors

Staphylococcus aureus is the main etiological agent of hordeolum, colonizes the eyelid margin and proceeds to the glandular structures, causing the suppurative inflammation in most cases (1,3,4). Coagulase-negative staphylococci, Streptococcus species, and gram-negative organisms are less frequently associated with the etiology of hordeolum, especially when recurrent or healthcare-associated cases are considered. Chalazia are caused by mechanical obstruction of the orifices of meibomian glands, which may be thickened sebum, desquamated epithelial cells, or seeding by secondary infection, hematogenously or by autoinoculation, during lid handling (8).

Some risk factors put people at risk of both conditions. Main causes include chronic blepharitis, which is inflammation of the lid margin, which promotes glandular dysfunction and bacterial overgrowth (9,7,8). And systemic disorders, including diabetes mellitus, promote the development of glands into severe or recurrent infections. Behavioral variables such as lack of eyelid hygiene, lower frequency of scrubbing the lid, and extensive contact lens wear provide an optimal habitat to bacterial invasion and obstruction of the glands (10,9).

Epidemiology

Hordeola and chalazia are some of the commonest eyelid disorders that are seen in primary care and in ophthalmology practice across the world (9). In a thorough review of Dutch primary care morbidity data, an incidence of 28.3 per 10,000 person-years (with slightly higher incidence in women) and the highest prevalence in the age bracket of 40 59 years was reported (ICPC code F72), comprising blepharitis, hordeolum, and chalazion (ICPC code F72).(9) Hordeola is a disease in particular, forming about 1520 percent of all eyelid lesions that are presented to general practitioners, indicating that this disease is of an acute nature and symptomatic (7). Although less acutely symptomatic, chalazia are also very common, especially in patients who have chronic lid disease.

Recurrence is significant, with chalazia recurring in up to 20% of cases in those people with MGD, and the underlying glandular pathology seems to have a significant part to play in the development of chalazia (9,8). Hordeola is more common in pediatric patients because rates of lid manipulation and inadequate hygiene are higher, and chalazia is more common in adults with chronic inflammatory disease.(5).

Pathophysiology

Hordeolum starts with the bacteria colonizing the eyelid margin, which is followed by the infiltration of neutrophils, release of cytokines, and development of an abscess in 48-72 hours in a pathophysiological cascade preceded by an acute inflammatory reaction (1,4). The accumulation of the pus that occurs causes pressure on the neighboring tissues, causing pain and erythema. Self-puncture through the skin (external) or conjunctiva (internal) is usually self-limiting and self-healing (2).

The ductal acinus is obstructed in chalazion formation, leading to a build-up of lipids, which may rupture the gland acinus, resulting in rupture of the gland acinus into the tarsal plate. Fibrosis encloses the lesion over several weeks in the form of a nodule that is hard and painless.

Polymorphonuclear leukocytes are introduced in the granulomatous milieu by secondary infection of a chalazion to transform the process into chronic or acute suppurative inflammation (10,8). The infected chalazion can evolve the central necrosis, fluctuance, and even fistulization and can resemble a large internal hordeolum.

Staging/Classification

The anatomical classification of hordeola includes external hordeola (which includes the lash follicle and gland of Zeis) and internal hordeola (which includes every other gland of the eyelid) (1,3,4). External hordeola includes the presence of a discrete pustule at the lid margin and anterior lid swelling. Internal hordeola influences the meibomian glands in the tarsal plate, leading to inflammation of the back lids, conjunctival injection, and increased edema (2). Chalazia are not graded but have been clinically characterized as early (soft, fluctuant, <2 weeks) or late (firm, fibrotic, >1 month) (6).

Clinical severity of infected chalazia include localized (localized to tarsus including tenderness and erythema) or complicated (with preseptal cellulitis, abscess formation, or systemic symptoms) according to the persistence of the lesion (more than two months) or some unusual characteristics (e.g., ulceration, madarosis) that can justify histopathology to rule out sebaceous cell carcinoma or basal cell carcinoma (7,8).

Signs and Symptoms

The symptoms of hordeolum are characterized by the onset of local pain, swelling of eyelids, and erythema and reach their highest point within 48-72 hours in nature (1,2,4). The patients complain of having a foreign body sensation, augmented tears, and photophobia. A yellow pustule can be either identified at the lid margin (external) or everted palpebral conjunctiva (internal) (5). Exquisite tenderness and warmth are palpated.

Uninfected chalazia are painless, hard, and non-tender, and are usually found by chance in the routine examination process (5). When infected a second time, the lesion turns acutely painful, warm, erythematous, and may or may not have fluctuance and spontaneous purulent drainage (7,8). The lesion is accompanied by diffuse lid edema, conjunctival chemosis, and, in severe cases, fever or regional lymphadenopathy of the lesion is secondary to preseptal cellulitis. Large tarsal masses may induce corneal astigmatism and, therefore, visual disturbance.

Management

The treatment of hordeolum and infected chalazion initially is a conservative one. Elevation in blood flow, liquefaction of meibum, and spontaneous drainage: Warm compresses used for 10-15 minutes, four to six times a day, will result in resolution in 70-80% of cases and in one to two weeks (10,5).

Topical antibiotics, e.g., erythromycin or bacitracin ointment twice daily, are recommended in cases of external hordeola or the onset of the infection in chalazia with visible purulence (82% vs. 78%), meaning little additional benefit in simple cases (10,4). Oral antibiotics, e.g., doxycycline 100 mg two times daily or cephalexin 500mg four times daily for 7-10 days, are advised in case of extensive preseptal involvement, recurrent cases. (10,8)

Surgery is done in cases where the lesions have continued after two weeks or where they have formed an abscess. A vertical tarsal incision, removal of granulomatous or purulent tissue, and curette scraping of the cavity are the main steps in incision and curetage, which has cure rates of over 90%.(6) Adjunctive intralesional triamcinolone acetonide (5-10mg/mL) could be faster in resolving recurrent chalazia, but there is limited evidence from randomised trials (6). New non-surgical treatments, such as the use of botulinum toxin and intense pulsed light therapy, have not been firmly supported in clinical trials in the application of these for infected lesions (6).

Complications

Live chalazia or hordeola can cause severe after-effects in case of delayed or insufficient treatment. Other, less common, potentially life-threatening complications are orbital cellulitis, subperiosteal abscess, and cavernous sinus thrombosis, especially in diabetic or immunocompromised persons (8). Persistent chalazia can cause mechanical ptosis, corneal astigmatism due to tarsal pressure, or margin deformity of the eyelid (8). The frequent infections are a warning sign of underlying blepharitis or rosacea that responds to long-term doxycycline, omega-3 supplements, or lid thermotherapy (9). The persistent lesions can be misdiagnosed as benign, and thus, this point highlights the importance of biopsy in case of uncharacteristic or recalcitrant cases of sebaceous cell carcinoma (8).

References

  1. Bragg KJ, Le PH, Le JK. Hordeolum (Archived). In: StatPearls (Internet). Treasure Island (FL): StatPearls Publishing; 2025. https://europepmc.org/article/NBK/nbk441985
  2. Rupani SR. Hordeolum and chalazion. JAAPA. 2023;36(6):43-4. https://doi.org/10.1097/01.JAA.0000931468.68794.aa
  3. Willmann D, Guier CP, Patel BC, Melanson SW. Hordeolum (Stye) (Updated 2024 Dec 11). In: StatPearls (Internet). Treasure Island (FL): StatPearls Publishing; 2025 Jan. https://www.ncbi.nlm.nih.gov/books/NBK459349/
  4. Alsoudi AF, Ton L, Ashraf DC, Idowu OO, Kong AW, Wang L, et al. Efficacy of care and antibiotic use for chalazia and hordeola. Eye Contact Lens. 2022;48(4):162-8. https://doi.org/10.1097/ICL.0000000000000859
  5. Lichtenstein SJ. What is the difference between a stye (hordeolum) and a chalazion, and how are they treated? In: Curbside consultation in pediatric ophthalmology. Boca Raton (FL): CRC Press; 2024. p. 83-6. https://www.taylorfrancis.com/chapters/edit/10.1201/9781003523673-21/difference-stye-hordeolum-chalazion-treated-steven-lichtenstein
  6. Tashbayev B, Chen X, Utheim TP. Chalazion treatment: a concise review of clinical trials. Curr Eye Res. 2024;49(2):109-18. https://doi.org/10.1080/02713683.2023.2279014
  7. Carlisle RT, Digiovanni J. Differential diagnosis of the swollen red eyelid. Am Fam Physician. 2015;92(2):106-12. https://www.aafp.org/pubs/afp/issues/2015/0715/p106.html
  8. Gordon AA, Danek DJ, Phelps PO. Common inflammatory and infectious conditions of the eyelid. Dis Mon. 2020;66(10):101042. https://doi.org/10.1016/j.disamonth.2020.101042
  9. Beekwilder H. Blepharitis/hordeolum/chalazion (F72). In: Morbidity in primary care; 2023. p. 26. https://library.oapen.org/bitstream/handle/20.500.12657/85107/1/morbidity-in-primary-care.pdf#page=26
  10. Lindsley K, Nichols JJ, Dickersin K. Non-surgical interventions for acute internal hordeolum. Cochrane Database Syst Rev. 2017;(1):CD007742. https://doi.org/10.1002/14651858.CD007742.pub4

Leave a Reply