Internal Hordeolum

A 42-year-old female presented to our clinic with a chief complaint of a “painful lump” on her right lower eyelid. It initially presented as a painless condition three days earlier, but it had become progressively larger and more uncomfortable in the interim. Additional questioning revealed a past history of “styes” and dry eyes. She reported that this lesion was tender to palpation.

Biomicroscopy revealed edema of the left eyelid and diffuse stenosis and occlusion of multiple meibomian gland orifices in both the upper and lower lids OD and OS. Only the right lower lid was tender to expression; however, stenosis of the meibomian gland orifices and generalized thickening of meibum was noted in all four eyelids. The anterior segments were otherwise unremarkable.

Our initial diagnoses were generalized meibomian gland dysfunction OD and OS and an internal hordeolum in the right lower eyelid. A hordeolum must be differentiated from several other similar conditions of the eyelids including chalazion, atopic dermatitis, neoplastic changes, contact dermatitis, and herpes zoster ophthalmicus.¹ In this case, the history of discomfort, rapid onset, and clinical presentation strongly suggested a clinical diagnosis of an internal hordeolum.²

A hordeolum is defined as “a common, painful inflammation of the eyelid margin that is usually caused by bacterial infection.”² It may be external (also known as a stye) (i.e., affecting the glands of Zeis or Moll) or internal (i.e., affecting the tarsal or meibomian glands).² Unresolved acute internal hordeola may become chronic or may eventually become a chalazion. Obtaining a dermatologic history may be useful; patients who have conditions such as acne rosacea and seborrheic dermatitis are predisposed to meibomian gland dysfunction.³

Lindsley et al evaluated the literature to determine which forms of intervention were most effective in treating/managing internal hordeola.² These included warm compresses applied at home, over-the-counter topical medications and lid scrubs, antibiotics or steroids, and lid massage. Their findings were somewhat surprising but very informative. They reported that use of warm eyelid compresses, the most commonly prescribed intervention for internal hordeola, did not accelerate healing time or reduce symptoms associated with this condition.² They also found that both medical treatment and lid hygiene are effective therapies in the management of acute internal hordeola.²

Although uncommon, potentially severe complications secondary to internal hordeola are possible.⁴ Because the eyelids are very thin, severe infection may compromise lid function and require surgical intervention. Rossetto et al reported a case of upper eyelid necrosis secondary to unresolved internal hordeola. Even after treatment with intravenous amoxicillin and clavulanate potassium 500mg/125mg b.i.d., the patient had significant lid damage and ultimately required surgical intervention.⁴

In the case of our patient, we prescribed a generic of the combination of amoxicillin 500mg with the beta lactamase inhibitor, clavulanate potassium, 5mg every 12 hours for seven days, and the condition resolved without sequelae. We also prescribed long-term therapy of a dry eye nutritional supplement twice daily.

References

1. Carlisle RT, Digiovanni J. Differential Diagnosis of the Swollen Red Eyelid. Am Fam Physician. 2015 Jul 15;92:106-112.
2. Lindsley K, Nichols J, Dickersin K. Interventions for acute internal hordeolum. Cochrane Database Syst Rev. 2013 Apr 30;4:CD007742.
3. Arbabi EM , Kelly RJ, Carrim ZI. Chalazion. BMJ. 2010 Aug 10;341:c4044.
4. Rossetto JD, Forno EA, Morales MC, et al. Upper Eyelid Necrosis Secondary to Hordeolum: A Case Report. Case Rep Ophthalmol. 2021 Apr 19;12:270-276.