Stye
Disease Entity
A stye (or hordeolum) is an inflamed oil gland on the margin of the eyelid at the level of the eyelashes or in the midportion of the eyelid. It appears as a red, swollen nodule that resembles a pimple in appearance. It is sometimes tender in its acute presentation, especially to the touch.
Hordeola may be on the external or internal surface of the eyelid and may lead to edema of the entire lid. If they are external, they originate from the glands of Zeiss or Moll. If they are internal, they originate from the meibomian glands.
At times, purulent material is released from the outer eyelash line in external hordeola, while internal hordeola exude on the inner conjunctival surface of eyelid. A stye that is chronic or long standing is likely to be a chalazion (typically painless but sometimes can be tender due to inflammation of the meibomian oil glands of the eyelid).
Etiology
A stye is caused by an obstruction of a meibomian gland and/or inflammtion contributed by normal bacteria or mites (demodex) from the skin of the eyelids. Styes are similar to common acne eruptions that occur elsewhere on the skin. As there are 20-25 meibomian glands per eyelid, patients may have more than one stye at the same time. They commonly develop over a few days and may drain and heal without treatment.
Staphylococcal bacteria are the most common causes of eyelid infections, but other organisms normally found on the skin may be precipitating factors.
Hordeola are found more frequently in patients with dry eyes and chronic blepharitis (eyelid inflammation often related to demodex).
Pathophysiology
Staphylococcus aureus is the bacteria responsible for the majority of cases of hordeolum.
An external hordeolum arises from a blockage with secondary inflammation of the Zeiss or Moll sebaceous glands of the eyelid. An internal hordeolum is a secondary inflammatory response of the meibomian glands in the tarsal plate.
If left untreated, chalazia may spontaneously resolve or may progress to chronic granulation with formation of a painless eyelid nodule. Chalazia may become large and can cause ptosis (drooping of the eyelid) with visual interference that may put pressure on and alter the shape of the cornea, leading to induced astigmatism or reduction in the superior peripheral visual field. Although rare, cellulitis of the eyelid may occur if an internal hordeolum is untreated. Most morbidity is secondary to improper drainage of the inflamed tissue.
Primary prevention
Daily eyelid hygiene with a mild soap and warm water is necessary to reduce the incidence of styes. Eyelid and face make-up should be removed completely before going to sleep.
It is important to wash hands thoroughly before touching the skin around the eye. Patients who are susceptible to styes should carefully clean excess oils from the eyelid margin. Commercial eyelid scrubs are available and may be recommended by an eye doctor as primary prevention for styes. These are especially useful if the diagnosis of a demodex infection has been made.
Diagnosis
History
Patients usually report a localized painful swelling of one or more eyelids. In some cases, the complaint may start as a generalized edema and erythema of the lid that later becomes localized.
A history of previous similar presentations is common.
Generalized changes in vital signs and systemic symptoms are extremely rare in the presentation of a hordeolum, though patients may notice their development in times of stress, poor diet, lack of sleep or illness.
In extreme cases, the condition may spread to involve the entire eyelid and even the adjacent facial tissues. These cases do not respond to conservative hordeolum management and must be treated as periorbital cellulitis, requiring oral and/or IV antibiotics.
There has been a documented rise in stye formation during the COVID 19 pandemic. This is believed to be due in part to mask wear and the redirection of breath upward, fogging glasses, drying eyes, and perhaps even changing the eyelid microbiome.
While mask wear is essential during a pandemic, antibacterial and viral lid scrubs, mouthwash, use of a mask with a nose clip, frequent washing of masks, and avoidng touching the face is recommended to mitigate the factors that contribute to stye formation.
Physical examination
A complete examination of the periocular area, the eye, and the conjunctival surface should be performed. Careful inspection the underside of the eyelid is necessary to distinguish an external from internal hordeolum.
Examination reveals a localized, tender, erythematous, elevated area with a pointing eruption either on the inner or outer side of the eyelid.
Palpation of adjacent lymph nodes can help to identify spread of the disease beyond an uncomplicated eyelid lesion. Lymph nodes should not be involved in patients with a simple hordeolum.
Visual acuity, slit lamp, and dilated funduscopic exam is necessary to rule-out extension of eyelid pathology.
Differential diagnosis
- Xanthelasma
- Papilloma
- Oil gland cyst /Tarsal cyst
- Pyogenic Granuoloma
- Carcinoma
- Amyloid Deposition
Management
Consultation with an ophthalmologist or ophthalmic plastic surgeon is necessary for appropriate diagnosis and management.
Medical therapy
Styes and chalazia may be treated by applying warm compresses to the eyelid several times per day. This helps to accelerate drainage of the lesion. Antibiotic ointments or drops with concomittant steroid may help styes resolve more quickly. Regular follow-up with an ophthalmologist is necessary to chronicle regression and monitor side effects from medications. In some cases, injection of triamcinolone (Kenalog) can help in resolving the lesion, although this carries the small risks of skin deposition of the steroid, necrosis, subcutaneous fat atrophy, embolic visual loss, incomplete resolution and need for surgical removal, as well as skin hypo-pigmentation or hyper-pigmentation (particularly in patients with darker skin tones).
Surgery
If a chalazion does not resolve with medical therapy, surgical incision and drainage may be recommended.
Patients are prepped with antiseptic solution and draped in the usual sterile fashion for ophthalmic surgery of the eyelids. Local anesthetic is injected into the eyelid lesion via either the skin or conjunctival surface or both.
A chalazion clamp is used to hold the eyelid in place centered on the chalazion. The eyelid is everted.
Drainage may be performed with a stab incision overlying the lesion using a #11 blade. External incisions may lead to scarring, so making external eyelid incisions or punctures are less desirable unless the chalazion is strongly pointing to the skin surface. In this case, the incision should be made directly overlying the area of skin thinning and lesion pointing.
Internal incisions may be made vertically along the length of the meibomian gland. This self sealing incision reduces the area of the cornea irritated during healing of the incision. A small chalazion curette is used to remove the content of chalazion. A small iris scissor may be used to remove the cystic wall of the chalazion. Hemostasis may be maintained with cautery.
The incision is left open with clean margins to allow for drainage of any residual material within the lesion. The eyelid may be patched closed over ointment for a few hours.
Complications
Cosmetic deformity and visual disturbance are the most common complications of styes.
If left untreated, styes may rarely lead to more widespread infections that involve the periorbital tissues. Also, stye recurrence is common especially if a prophylactic daily lid hygiene is not maintained.
Complications of improper drainage include disruption of lash growth, eyelid notch deformity, or eyelid fistula.
Additional Resources
- Turbert D, Gregori NZ. Eyelashes. American Academy of Ophthalmology. EyeSmart/Eye health. https://www.aao.org/eye-health/anatomy/eyelashes. Accessed March 07, 2023.
- Porter D, Mendoza O, Turbert D. Inflammation. American Academy of Ophthalmology. EyeSmart/Eye health. https://www.aao.org/eye-health/symptoms/inflammation. Accessed March 07, 2023.
References
- http://emedicine.medscape.com/article/798940-overview
- Orbit, Eyelids, and Lacrimal System. BCSC Section 7. American Academy of Ophthalmology. 2008.
- Techniques in Ophthalmic Plastic Surgery with DVD: A Personal Tutorial. Jeffrey A. Nerad MD. Saunders 2010.
- Silkiss, RZ, Paap, MK, Ugradar, S, The Association between Mask Wear and Chalazion Formation during the Covid-19 Pandemic, AJO Case Reports, 2020.
