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Summary Table

Category	Key Points
Risk Factors	Chronic blepharitis, rosacea, seborrheic dermatitis, diabetes mellitus, poor lid hygiene, contact lens use, eye rubbing, prior history of stye
Etiology	*Staphylococcus aureus* in over 90% of cases; acute bacterial infection of an eyelid gland
Patient Presentation	Acute onset (1 to 3 days) of a painful, red, tender lump on the eyelid; foreign body sensation; tearing; mild photophobia
Classic Physical Exam	Localized, erythematous, warm, tender nodule on the lid margin (external) or deeper within the tarsal plate (internal); may have a yellow pustule pointing at the lash line; vision and pupillary reflexes are normal
Key Diagnostic Results	Clinical diagnosis; no imaging or labs required in straightforward cases
Management	Warm compresses 10 to 15 minutes, 4 times daily; lid hygiene; topical erythromycin ointment if draining; incision and drainage if persistent beyond 1 to 2 weeks
Keywords	"Painful red bump on the eyelid," "tender nodule at lash line," "pointing pustule," "stye," "acute lid swelling with localized tenderness"

1. Pathophysiology

A hordeolum is an acute, suppurative (pus-forming) infection of an eyelid gland, almost always caused by Staphylococcus aureus. The infection arises when the duct of an eyelid gland becomes obstructed, allowing bacteria from the lash line to colonize trapped sebaceous or sweat material.

There are two anatomical subtypes you must distinguish, because the test will reward you for knowing the gland involved:

External hordeolum is the more common form. It involves the glands of Zeis (sebaceous glands attached to lash follicles) or the glands of Moll (apocrine sweat glands). Because these glands sit at the lid margin, the lesion points outward toward the skin at the base of an eyelash.
Internal hordeolum involves the meibomian glands, which are deeper in the tarsal plate. The abscess points inward toward the conjunctival surface and tends to be larger, more painful, and slower to resolve.

The pain and tenderness arise from acute inflammation in a confined space: the tarsal plate and surrounding tissue are unyielding, so even a small abscess raises local pressure on nerve endings. The foreign body sensation comes from the swollen lid rubbing against the cornea with each blink. Crucially, a true hordeolum is acute and tender, while a chalazion (its closest mimic) is chronic and painless because it is a sterile granulomatous reaction rather than an active infection.

A patient with chronic blepharitis is the classic vignette setup: the inflamed lid margin promotes gland obstruction and seeds the area with staphylococci, predisposing to recurrent styes. Diabetes and immunocompromise lower the threshold for both occurrence and progression to preseptal cellulitis, which is the complication you must watch for.

2. Diagnostic Workup

Test	Purpose	When to Order
Visual acuity testing	Rule out vision-threatening pathology	Routine in any acute red eye complaint
Eversion of the eyelid	Identify internal hordeolum on the conjunctival surface	When external inspection is unrevealing despite lid pain
CT scan of orbits	Rule out orbital cellulitis	Only if proptosis, ophthalmoplegia, pain with eye movement, or vision loss
Bacterial culture	Identify resistant organisms	Recurrent or treatment-resistant cases
Biopsy	Rule out sebaceous cell carcinoma	Recurrent unilateral lesion in the same location, especially in elderly patients

Hordeolum is a clinical diagnosis. The best initial test and the most accurate test are one and the same: a focused history and external eye exam. The vignette will describe a tender, erythematous nodule on the lid, with normal visual acuity, normal extraocular movements, no proptosis, and a normal pupillary exam. Recognizing that this constellation requires no further workup is itself a testable point.

The reason you must always document visual acuity, pupillary response, and extraocular movements is to exclude the entities that do require imaging. If the patient has pain with eye movement, proptosis, ophthalmoplegia, or decreased vision, you are no longer dealing with a stye. Those red flags mandate CT of the orbits with contrast to evaluate for orbital cellulitis, which is a sight-threatening and life-threatening emergency.

A practical pearl: in a recurrent lesion at the same site in an older adult, the next best step is biopsy, not another round of antibiotics. This is to rule out sebaceous cell carcinoma, which masquerades as a chronic chalazion or hordeolum and is a classic exam trap.

3. Management and Treatment

Step	Intervention	Details
First-line (acute)	Warm compresses	10 to 15 minutes, 4 times daily, for 5 to 7 days
Adjunct	Lid hygiene with diluted baby shampoo or commercial lid scrubs	Twice daily
If draining or pointing	Topical antibiotic ointment	Erythromycin 0.5% or bacitracin, applied to the lid margin twice daily for 7 to 10 days
If preseptal cellulitis develops	Oral antibiotics	Amoxicillin-clavulanate 875/125 mg twice daily, or doxycycline; cover MRSA with trimethoprim-sulfamethoxazole or clindamycin if local prevalence is high; treat for 7 to 10 days
If unresolved at 1 to 2 weeks	Incision and drainage by ophthalmology	Vertical incision on the conjunctival side for internal hordeolum; horizontal on the skin side for external
Long-term (recurrent)	Treat underlying blepharitis or rosacea	Daily lid hygiene; oral doxycycline 100 mg daily for 1 to 3 months in rosacea-related cases

The cornerstone of acute management is conservative therapy with warm compresses. Heat softens the inspissated material in the obstructed gland, promotes spontaneous drainage, and improves blood flow to clear the infection. Most styes resolve within 5 to 7 days with compresses alone. This is the single highest-yield management point: the next best step in an uncomplicated hordeolum is warm compresses, not antibiotics.

Topical antibiotics are reserved for lesions that are actively draining, have a clear pointing pustule, or are associated with concurrent blepharitis or conjunctivitis. They do not penetrate well into a closed abscess, so giving them to a non-draining stye is low-yield and a common wrong answer.

Oral antibiotics are indicated only when the infection has spread beyond the gland. The signs to recognize are diffuse lid edema, erythema extending onto the cheek or forehead, fever, and warmth, signaling preseptal cellulitis. First-line outpatient therapy is amoxicillin-clavulanate for 7 to 10 days. If you see proptosis, painful eye movement, or vision loss, you have escalated to orbital cellulitis, which mandates hospital admission and intravenous antibiotics (vancomycin plus ceftriaxone or ampicillin-sulbactam) along with urgent ophthalmology and ENT consultation.

Incision and drainage is the next best step when a hordeolum persists beyond 1 to 2 weeks despite conservative therapy, has become very large, or is pointing and fluctuant. This must be performed by an ophthalmologist. Patients should never attempt to squeeze or pop a stye, as this can spread infection into the orbit.

For recurrent hordeola, the treatment shifts from the lesion itself to its underlying cause. Patients with rosacea or chronic blepharitis benefit from oral doxycycline 100 mg daily for 1 to 3 months, which works through both anti-inflammatory effects and modulation of meibomian gland secretions. Doxycycline is contraindicated in pregnancy and in children under 8 because of effects on bone and tooth development; in those populations, erythromycin is the preferred substitute.

4. Differential Diagnosis and Distractors

Differential Diagnosis	Why It's Similar	Key Discriminator
Chalazion	Both present as a lid nodule	Chalazion is painless, chronic, firm, and rubbery, located in the mid-tarsal plate, not at the lid margin; it is a sterile granuloma, not an infection
Preseptal (periorbital) cellulitis	Both cause red, swollen, tender eyelid	Cellulitis has diffuse lid edema and erythema without a discrete nodule; vision and eye movements remain normal but the entire lid is affected
Orbital cellulitis	Both cause periocular pain and swelling	Orbital cellulitis presents with proptosis, painful and limited eye movements, decreased visual acuity, and afferent pupillary defect; mandates CT and IV antibiotics
Blepharitis	Both cause lid irritation and erythema	Blepharitis is bilateral, chronic, and diffuse along the entire lid margin with crusting and scaling, without a focal nodule
Dacryocystitis	Both cause painful, red lid swelling	Dacryocystitis is located medially, over the lacrimal sac, below the medial canthus, with purulent discharge expressible through the punctum
Sebaceous cell carcinoma	Can present as a recurrent lid nodule	Recurrent or non-resolving lesion at the same site, especially in elderly patients; loss of eyelashes (madarosis) over the lesion; requires biopsy
Molluscum contagiosum of the lid	Both cause a lid bump	Molluscum is a painless, umbilicated, pearly papule without erythema or tenderness

5. Traps and High-Yield Pearls

The most common way students miss this question is by over-treating. When a vignette describes a tender lid nodule with normal vision, normal eye movements, and no proptosis, the answer is warm compresses, not oral antibiotics, not topical antibiotics, and certainly not incision and drainage. Test-writers reliably plant antibiotics as a tempting distractor because students panic at the word "infection." Resist that pull: a localized, uncomplicated stye is treated with heat.

The second classic trap is failing to distinguish hordeolum from chalazion. The discriminator the test wants you to identify is the acute, tender, and erythematous nature of a hordeolum versus the chronic, painless, and rubbery quality of a chalazion. If the vignette uses the word "tender" or describes recent onset over days, it is a hordeolum; if it says "for several weeks, painless, and gradually enlarging," it is a chalazion.

The third trap, and the one that distinguishes a strong test-taker, is recognizing the red flags that take you out of hordeolum territory entirely. Proptosis, painful or restricted eye movements, decreased visual acuity, or an afferent pupillary defect mean you are looking at orbital cellulitis, and the next best step is no longer warm compresses but rather CT of the orbits and admission for intravenous antibiotics. Missing this escalation costs the patient their eye, and on the exam, costs you the question.

The fourth pearl, frequently embedded in subtle vignettes, is the recurrent unilateral lesion in an elderly patient. The reflex answer of "another stye, prescribe warm compresses" is wrong. The correct next step is referral for biopsy to exclude sebaceous cell carcinoma, particularly if the vignette mentions loss of eyelashes over the lesion or thickening of the lid.

The core competency being tested is clinical pattern recognition combined with appropriate restraint: knowing when a condition is benign and self-limited, knowing when it has crossed into a sight-threatening complication, and knowing when an apparently routine presentation hides a malignancy. A confident answer requires you to read the entire vignette for those red flags before committing to therapy.

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