A 6-year-old male came to clinic with a 2 day history of painful right eyelid swelling. His mother noticed the top lid was red, swollen in 1 discrete area and was mildly painful. He denied any problems seeing and his mother agreed that he did not have problems walking or doing other activities because of visual problems. They noticed some debris on the lashes that was crusted especially when awakening. He had not had any prior eyelid or other ophthalmological problems. The review of systems was negative for fever or other current or recent infectious diseases.
The pertinent physical exam showed a well-appearing male. Vital signs were normal and growth parameters were 50-90% for age. Visual acuity was 20:20 by Snellen chart. Extra ocular movements were intact. The left eyelid margin showed one 2-3 mm swelling with a central area that pointed outward that was slightly yellowish. There was mild erythema of the swelling and surrounding tissue. There were no other lesions noted with eversion of the eyelid. The right eye was normal as was the rest of the examination. The diagnosis of a simple external hordeolum was made. The family was instructed to do warm compresses for 15 minutes four times/day. They were to call if the swelling or pain increased, or if changes in vision or generalized symptoms such as fever developed. They were also instructed to call if the hordeolum did not appear to be improving in about 3 days.
There is confusion with the terms stye, hordeolum and chalazion because of the general public usage and the most precise medical usage. Even in the more precise usage, there is difficulty because of the overlap in the anatomy.
Hordeola and chalazia can be caused by blepharitis or generalized eyelid inflammation. A differential diagnosis of blepharitis can be found here.
Stye is a term used often by the general public to denote a small localized swelling/inflammation of the eyelid.
A hordeolum (or a stye) is term used by the medical profession to denote a localized inflammation and/or infection of the hair follicles of the eyelid or the meibomian glands. It is usually an acute problem but can be recurrent. These are usually somewhat painful with erythema and the entire general eyelid may be edematous. Generalized cellulitis can also occur. In 90-95% of cases, Staphylococcus aureus is the cause. Treatment is mainly with warm compresses (four times/day), but sometimes incision to aid drainage is needed. Topical antibiotics may be helpful for recurrent or actively draining hordeola. Ophthalmologic consultation is recommended if not improving in 2-3 days.
- External hordeolum – a hordeolum of hair follicles that usually has its leading edge pointing externally to the eyelid. It affects the sebaceous glands of Zeis or the apocrine sweat glands of Moll which both service the hair follicles. There is often purulent material on the eyelashes and lid margin.
- Internal hordeolum – a hordeolum of the meibomian glands lying within the tarsal plates that usually has its leading edge point internally to the eyelids. Purulent material may be seen on the conjunctival surface of the eyelid.
- Hordeola may also be bi-directional.
A chalazion is a term used by the medical profession to denote a swelling caused by blockage of sebaceous glands and formation of granulomas. It usually occurs in the meibomian glands in the tarsal plates, but also can occur in the sebaceous glands of Zeis. It is a chronic problem and it is usually painless. Internal hordeola may lead to chalazia. Chalazia can become quite large and put pressure on the cornea and thereby cause visual changes.
Chalazia usually are treated with warm compresses (4 times/day). Washing the eyelashes with a baby shampoo may also help with lid hygiene and improves control of seborrheic dermatitis if present. Antibiotics are usually not used unless there is an additional secondary infection. Ophthalmologic referral is usually made after 2 weeks and treatment at that time may include surgical drainage or steroid injection.
Questions for Further Discussion
1. What are indications for ophthalmology consultations?
2. When can a child’s visual acuity be evaluated in a health supervision visit?
- Disease: Hordeolum | Eye Lid Disorders
- Symptom/Presentation: Mass or Swelling | Eye Pain
- Specialty: General Pediatrics | Ophthalmology
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Eyelid Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Bessette MJ. Hordeolum and Stye. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/798940-overview (rev. 2/24/2010, cited 5/24/2010).
Fansler JL, Schraga ED, Santen S. Chalazion. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/797763-overview (rev. 4/27/2010, cited 5/24/2010).
Dictionary.com. Chalazion – http://dictionary.reference.com/browse/chalazion,(cited 5/24/2010)
Dictionary.com. Hordeolum – http://dictionary.reference.com/browse/hordeolum,(cited 5/24/2010)
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital