|
| |
AUTHOR INFORMATION
| Section 1 of 11   |
|
| Author: George Alexandrakis, MD, Consulting Staff and Surgeon, Department of Ophthalmology, Southern California Permanente Medical Group |
| George Alexandrakis, MD, is a member of the following medical societies:
American Academy of Ophthalmology |
| Editor(s): Fernando H Murillo-Lopez, MD, Instructor, Department of Ophthalmology, Private Ophthalmology Unit at C.E.M.E.S.; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine;
Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Hospital;
Lance L Brown, OD, MD, Ophthalmologist, Regional Eye Center, Affiliated With Freeman Hospital and St John's Hospital, Joplin, Missouri;
and Hampton Roy, Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences |
Disclosure
| |
INTRODUCTION
| Section 2 of 11   |
|
Background: A hordeolum is one of the most common disorders of the eyelid. Clinically, it is often difficult to differentiate a hordeolum from an acute chalazion. Therefore, both terms are used in this chapter to describe the same disorder. Pathophysiology: This lesion represents a focal, chronic, nodular granuloma of the eyelid resulting from an obstruction of the Zeis or meibomian glands. The meibomian glands are oil-producing sebaceous glands located in the tarsal plates of the eyelids. Obstruction of the meibomian glands results in release of the contents of the glands (sebum) into the tarsus and surrounding tissues causing a foreign body reaction.
Analysis of the lipids of chalazia has shown that they are similar to the membrane components of cell membranes rather than the lipids of the meibum, representing a “graveyard” of phagocyte cell membranes. An external hordeolum or stye is an acute infection of an eyelid gland associated with the follicle of a cilium and can be related to a staphylococcal infection. Frequency:
- In the US: A hordeolum is one of the most common eyelid lesions encountered in a general ophthalmology practice; however, no reports exist on the prevalence of this entity in the United States or internationally.
Race: No clinical evidence exists regarding a difference in incidence among specific races.
Sex: No clinical evidence exists regarding a difference in incidence among men and women.
Age: A hordeolum is usually encountered in the adult population and occasionally occurs in the pediatric population. In pediatric patients, these lesions are considered more difficult to treat successfully, probably because of a higher recurrence rate as compared to adults.
History: - A hordeolum usually has an acute onset, and a chalazion can present either acutely or insidiously. These patients often have a past history of a similar eyelid lesion and a past ocular history of blepharitis or meibomian gland disease.
- A history of ocular rosacea may be present.
- Symptoms include the following:
- Eye discomfort and burning sensation
Physical: - External examination reveals an acute inflammatory reaction with eyelid erythema and edema.
- Clinical features of ocular rosacea may be present.
- Cellulitis of the surrounding soft tissues may develop in external or internal eyelid lesions.
- The external hordeolum becomes localized and often drains anteriorly through the skin near the eyelash line.
- On slit lamp examination, clinical findings of eyelid margin inflammation are noted in patients with blepharitis and a history of recurrent or multiple chalazia.
Causes: - Multiple recurrent lesions have been associated with eyelid abnormalities such as blepharitis and meibomian gland dysfunction.
- The exact role of bacterial agents such as Staphylococcus aureus in the pathogenesis of a hordeolum remains unclear.
- A large cholesterol component has been found in specimens from a chalazion, and studies have reported an association of multiple chalazia with elevated serum cholesterol.
- Recent evidence points to multiple recurrent hordeola associated with selective immunoglobulin M (IgM) deficiency or hyperimmunoglobulinemia E.
| |
DIFFERENTIALS
| Section 4 of 11 |
|
Basal Cell Carcinoma, Eyelid
Cellulitis, Preseptal
Chalazion
Sebaceous Gland Carcinoma
Squamous Cell Carcinoma, Eyelid
|
|
Lab Studies:
- Diagnosis is based on the typical clinical presentation.
- The association with elevated serum cholesterol remains unclear; therefore, no laboratory studies are indicated in a patient presenting with a new lesion.
Histologic Findings: Histopathology of a hordeolum reveals an abscess or a focal collection of polymorphonuclear leukocytes and necrotic tissue. Histopathologically, chalazia represent chronic lipogranulomatous inflammatory changes. Clear spaces usually are seen within the granuloma representing the location of tissue lipid. Foreign body giant cells, epithelioid cells, polymorphonuclear leukocytes, macrophages, lymphocytes, and plasma cells also may be present.
Basal cell or sebaceous cell carcinoma of the eyelid can be misdiagnosed clinically as a recurrent hordeolum or chalazion; therefore, histopathologic examination is very important in determining the diagnosis, especially in patients with a persistent or recurrent lesion.
| |
TREATMENT
| Section 6 of 11 |
|
Medical Care: - Medical treatment consists of frequent daily use of warm compresses, eyelid hygiene, and topical anti-inflammatory medication in the acute inflammatory phase.
- Antibiotic therapy may be necessary in case of a secondary bacterial infection.
- If warm compresses and antibiotics do not lead to resolution, then intralesional injection of steroids or surgical incision and drainage of the lesion may be necessary. However, local steroid injection of triamcinolone in the center of the lesion (40 mg/mL, 0.2 mL) is not always recommended because it can result in depigmentation of the overlying skin, vascular occlusion, or visual loss.
- The inflammatory process of a hordeolum usually is self-limited with drainage and resolution occurring within 5-7 days.
- Lid hygiene and warm compresses often help in resolution of the lesion.
- In one study, 50% of lesions in adult patients improved or resolved with medical treatment within 6 weeks.
- Treatment of accompanying blepharitis or meibomianitis is important to prevent the formation of new lesions.
- Multiple lesions sometimes are treated with a course of oral antibiotics in conjunction with warm compresses and lid hygiene.
Surgical Care: - In some cases, the eyelid lesion becomes chronic and cystlike, requiring surgical incision and curettage under topical anesthesia.
- An incision through the conjunctiva and tarsus is performed when the inflammatory reaction is present on the posterior eyelid margin.
- An incision through the skin and orbicularis muscle may be necessary when the inflammatory reaction is located anteriorly.
- The specimen should be sent for histopathologic examination.
| |
MEDICATION
| Section 7 of 11 |
|
Medical treatment consists of frequent daily use of warm compresses and eyelid hygiene. Topical antibiotic therapy or a course of systemic antibiotics is occasionally necessary in the acute inflammatory phase of a hordeolum. However, inflammation usually is self-limited and most lesions resolve with conservative therapy. Intralesional administration of triamcinolone also can be used in some cases.
Drug Category: Antibiotics -- A course of oral antibiotic therapy is used in cases of a hordeolum accompanied with signs of an acute inflammation or infection of the eyelid. Drug Name
| Cephalexin (Keflex, Biocef, Keftab) -- First-generation cephalosporin often used in skin or skin structure infections (eg, acute hordeolum) caused by staphylococci or streptococci. Administered orally and has a half-life of 50-80 min. Only 10% is protein bound and greater than 90% recovered unchanged in urine. |
|---|
| Adult Dose | 250 mg PO qid or 500 mg PO bid for 7-10 d |
|---|
| Pediatric Dose | 20 mg/kg/d PO divided q8h for 7-10 d; in more serious infections, may increase dose to 40 mg/kg/d; not to exceed 1 g/d |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | Coadministration with aminoglycosides increase nephrotoxic potential |
|---|
| Pregnancy |
B - Usually safe but benefits must outweigh the risks.
|
|---|
| Precautions | Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy |
|---|
Drug Category: Corticosteroids -- Inhibit enzyme phospholipase and have a well-documented anti-inflammatory action.Drug Name
| Triamcinolone (Amcort, Aristospan Intra-Articular) -- Intralesional administration occasionally is indicated in patients presenting with a hordeolum. Periocular administration also is used in cases of steroid-responsive intraocular inflammation. Triamcinolone is relatively insoluble and has an extended duration that may be sustained for several weeks. |
|---|
| Adult Dose | Not established; 2-5 mg of intralesional triamcinolone acetonide usually sufficient |
|---|
| Pediatric Dose | Not established |
|---|
| Contraindications | Documented hypersensitivity; fungal, viral, and bacterial skin infections |
|---|
| Interactions | Coadministration with barbiturates, phenytoin, and rifampin decreases effects of triamcinolone |
|---|
| Pregnancy |
C - Safety for use during pregnancy has not been established.
|
|---|
| Precautions | Intralesional injections may cause skin atrophy, depigmentation, and even vascular occlusions resulting in visual loss; use with caution; prolonged use may result in glaucoma, optic nerve damage, posterior subcapsular cataract, increased risk of secondary ocular infections, and corneal thinning |
|---|
| |
FOLLOW-UP
| Section 8 of 11 |
|
Further Outpatient Care:
- Following initial examination and institution of medical treatment, follow-up examination is recommended in approximately 2-4 weeks to assess response to therapy and need for possible surgical incision and curettage.
Deterrence/Prevention:
- Treatment of accompanying blepharitis and meibomian gland dysfunction with daily warm compresses and lid scrubs is important to prevent the formation of new lesions.
Complications:
- Large lesions of the upper eyelid have been reported to cause decreased vision secondary to induced astigmatism or hyperopia resulting from central corneal flattening.
Prognosis:
- The inflammatory process of a hordeolum usually is self-limited with drainage and resolution occurring within 5-7 days. Lid hygiene and warm compresses often result in resolution of the lesion.
Patient Education:
| |
MISCELLANEOUS
| Section 9 of 11 |
|
Medical/Legal Pitfalls:
- Basal cell or sebaceous cell carcinoma of the eyelid can be misdiagnosed clinically as a recurrent hordeolum or chalazion. In these cases, a high degree of clinical suspicion should be present and histopathologic examination of the surgical specimen is important in determining the diagnosis.
| |
PICTURES
| Section 10 of 11 |
|
| Caption: Picture 1. A 22-year-old patient with no past medical or ocular history presents with a lesion consistent with an eyelid hordeolum.
|  |  View Full Size Image |
|
Picture Type: Photo |
| Caption: Picture 2. A 2-year-old healthy boy presents with an eyelid lesion clinically consistent with a hordeolum.
|  | View Full Size Image |
|
Picture Type: Photo |
| |
BIBLIOGRAPHY
| Section 11 of 11 |
|
-
Destafeno JJ, Kodsi SR, Primack JD: Recurrent Staphylococcus aureus chalazia in hyperimmunoglobulinemia E (Job's) syndrome. Am J Ophthalmol 2004; 138(6): 1057-8[Medline].
-
Hosal BM, Zilelioglu G: Ocular complication of intralesional corticosteroid injection of a chalazion. Eur J Ophthalmol 2003; 13(9-10): 798-9[Medline].
-
Kaimbo Wa Kaimbo D, Nkidiaka MC: Intralesional corticosteroid injection in the treatment of chalazion. J Fr Ophtalmol 2004; 27(2): 149-53[Medline].
-
Katowitz WR, Shields CL, Shields JA: Pilomatrixoma of the eyelid simulating a chalazion. J Pediatr Ophthalmol Strabismus 2003; 40(4): 247-8[Medline].
-
Kiratli HK, Akar Y: Multiple recurrent hordeola associated with selective IgM deficiency. J AAPOS 2001; 5(1): 60-1[Medline].
-
Lederman C, Miller M: Hordeola and chalazia. Pediatr Rev 1999 Aug; 20(8): 283-4[Medline].
-
Ozdal PC, Codere F, Callejo S: Accuracy of the clinical diagnosis of chalazion. Eye 2004; 18(2): 135-8[Medline].
-
Raskin EM, Speaker MG, Laibson PR: Blepharitis. Infect Dis Clin North Am 1992 Dec; 6(4): 777-87[Medline].
-
Shields JA, Demirci H, Marr BP: Sebaceous carcinoma of the eyelids: personal experience with 60 cases. Ophthalmology 2004; 111(12): 2151-7[Medline].
-
Shiramizu KM, Kreiger AE, McCannel CA: Severe visual loss caused by ocular perforation during chalazion removal. Am J Ophthalmol 2004; 137(1): 204-5[Medline].
Hordeolum excerpt |
){kind=small}
