Rosen & Barkin's 5-Minute Emergency Medicine Consult (351 page)

• Result from inflammatory processes involving the glands of the eyelid along the lash line:
  
  • Hordeolum—acute glandular obstruction resulting in inflammation and abscess formation
    
  • Chalazion—end result of inspissation of glandular contents and chronic granulomatous inflammation
    
• Hordeolum:
  
  • Develops owing to outflow obstruction in 1 or more of the glands of the eyelid
    
  • Obstructed glands may become secondarily infected.
    
  • May progress to localized abscess formation or may be complicated by periorbital cellulitis
    
• Chalazion:
  
  • Chronic granulomatous inflammation in the meibomian gland:
    
    • Originates from inspissated secretions
      
    • Blockage of the gland’s duct at the eyelid margin may result in release of the contents of the gland into the surrounding eyelid soft tissue.
      
    • A lipogranulomatous reaction ensues
      
    • Occasionally, chalazia become secondarily infected.
      
    • May evolve from incompletely drained internal hordeolum
      

Hordeolum:

• May become secondarily infected:
  
  • Staphylococcus most common
    
• Predisposing conditions:
  
  • Meibomian gland dysfunction
    
  • Blepharitis
    
  • Rosacea
    
  • Previous hordeolum
    

DIAGNOSIS

• Hordeolum:
  
  • Develops acutely when glandular outflow is obstructed
    
  • Red, tender, painful, swollen mass along the eyelid margin
    
  • Typically solitary, rarely may be multiple
    
  • May be recurrent
    
  • Well-localized inflammation
    
  • Presentation depends on which gland is affected:
    
    • External hordeolum (stye):
      
    • Originates from obstruction of the superficial sebaceous or sweat glands whose ducts are located between the eye lashes
      
    • Exquisitely tender small mass that typically points anteriorly
      
    • Internal hordeolum:
      
    • Originates from obstruction of the sebaceous glands whose ducts are located on the inner aspect of the lid margin
      
    • Painful small mass that is palpable through the eyelid
      
    • May cause a foreign body sensation in the eye and visual disturbance
      
    • Typically more inflamed, larger, and more painful
      
    • May point internally or through skin
      
  • Nonsystemic process
    
  • May be complicated by:
    
    • Conjunctivitis
      
    • Periorbital cellulitis
      
• Chalazion:
  
  • Firm, circumscribed, nontender, or minimally tender nodule:
    
    • Typically long standing
      
  • Noninflamed
    
  • Symptoms most commonly owing to physical properties:
    
    • Disrupts natural contour of eye
      
    • Obstructs visual field/peripheral vision
      
    • Pressure on globe
      
    • Corneal desiccation or injury due to exposure
      
  • Nonacute, nonemergent process, which requires no urgent or emergent intervention unless secondary corneal or significant globe pressure is present.
    

Hordeolum—sudden, well localized, painful mass along the margin of eyelid:

• No systemic symptoms
  

Focal, tender, inflammation of an external or internal gland of the eyelid:

• Minimal surrounding edema may be seen
  
• Abscess may point within lash line, from palpebral conjunctiva or externally via skin of the lid
  

• Complete ophthalmologic exam including slit lamp exam and corneal evaluation
  
• Evaluation for evidence of associated cellulitis and/or systemic findings
  
• Hordeolum:
  
  • Identify the origin of the abscess
    
• Chalazion:
  
  • Determine whether physical properties of chalazion result in corneal exposure and injury.
    

Cultures of any drainage rarely aids in management

• Blepharitis
  
• Dacryocystitis
  
• Dacryoadenitis
  
• Pyogenic granuloma
  
• Sebaceous cell carcinoma
  
• Basal cell carcinoma
  
• Squamous cell carcinoma
  

TREATMENT

• Hordeolum—relieve obstruction and prevent abscess formation
  
  • Warm compresses for 15 min 4–6 times per day
    
  • Gently massage the nodule to express obstructed material
    
  • Rarely, in severe cases, incision and drainage of internal hordeolum may be necessary:
    
    • Typically done by ophthalmologist
      
    • If pointed toward the conjunctiva, vertical incision is made to avoid injury to the meibomian glands and reduce corneal injury from inadvertent scarring.
      
    • External skin incision is very rarely indicated.
      
  • When necessary, horizontal incision is used
    
  • Removing single involved eyelash may be helpful in rare more severe cases of external hordeolum
    
  • Botox
    
• Chalazion—complaints typically reflect nonemergent aesthetic and cumbersome physical properties of the mass:
  
  • Referral to ophthalmology for incision and curettage or steroid injection
    
  • Lubricating eye drops may provide symptomatic relief
    

Ophthalmologic moisturizing drops as needed for comfort.

FOLLOW-UP

No indication for admission unless secondary complication is present (i.e., marked periorbital cellulitis with systemic symptoms)

• Urgent consultation with ophthalmologist should be considered if incision and drainage of internal hordeolum is deemed indicated.
  
• Chalazia should be referred to ophthalmologist for definitive treatment options.
  

• Follow-up with ophthalmology in 1–2 days to evaluate response to conservative management.
  
• Symptoms should complete resolve in 1–2 wk
  

• Conservative treatment of hordeola with warm compresses and gentle massage is the standard:
  
  • Majority of cases respond without further intervention
    
  • Emergent incision and drainage is rarely indicated and should only be considered in extreme cases
    
  • Incision and drainage may result in long-term complications including corneal injury, fistula formation, and aesthetic complications
    
  • Consult ophthalmology for incision and drainage if possible
    
• Chalazia do not require emergent intervention:
  
  • Referral is the standard management
    

• Cronau, Kankanala RR, Mauger T. Diagnosis and management of red eye in primary care.
  Am Fam Physician.
  2010;81(2):137–144.
  
• Goawalla A, Lee V. A prospective randomized treatment study comparing three treatment options for chalazia: Triamcinolone acetonide injections, incision and curettage and treatment with hot compresses.
  Clin Exp Ophthalmol.
  2007;35:706–712.
  
• Gomi CF, Granet DB. Common conditions affecting the internal eye.
  Pediatric Ophthalmol.
  2009;449–459.
  
• Lindsley K, Nichols JJ, Dickersin K. Interventions for acute internal hordeolum
  Cochrane Database Syst Rev
  . 2010;(9):CD007742.
  
• Zvandasara T, Diaper C. Tips for managing Chalazion InnovAiT: The RCGP.
  J Assoc Train.
  2012;5:133–136.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Dacryoadenitis
  
• Dacryocystitis
  
• Red Eye
  

CODES

• 373.2 Chalazion
  
• 373.11 Hordeolum externum
  
• 373.12 Hordeolum internum