The Clinical Picture

Hordeolum: Acute abscess within an eyelid sebaceous gland

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Figure 1.

An 89-year-old man presented complaining of a tender, painful lump in the right lower eyelid that spontaneously appeared 3 days previously. There was no discharge, bleeding, or reduced vision. He had a history of hypertension and macular degeneration. There was no history of a pre-existing eyelid lesion, ocular malignancy, rosacea, or seborrheic dermatitis. Examination of the right lower lid revealed a roundish raised abscess with surrounding erythema (Figure 1). The raised area was tender on palpation; there was no discharge. The palpebral conjunctiva was normal. A diagnosis of a hordeolum was made, and conservative treatment was prescribed, ie, warm compresses and massage for 10 minutes four times a day. The lesion improved gradually and resolved over 3 weeks.

Figure 2.

A hordeolum is an acute abscess within an eyelid gland, usually staphylococcal in origin. When it involves a meibomian gland it is termed an internal hordeolum, and when it involves the gland of Zeis or Moll it is termed an external hordeolum (Figure 2).1 Hordeola may be associated with diabetes, blepharitis, seborrheic dermatitis, rosacea, and high levels of serum lipids. Treatment is with warm compresses and massage. A hordeolum with preseptal cellulitis, signs of bacteremia, or tender preauricular lymph nodes requires systemic antibiotics (eg, flucloxacillin 250–500 mg four times a day for 1 week).

Preseptal cellulitis is an infection of the subcutaneous tissues anterior to the orbital septum. The orbital septum is a sheet of fibrous tissue that originates in the orbital periosteum and inserts in the palpebral tissues along the tarsal plates of the eyelid. The orbital septum provides a barrier against the spread of periorbital infection into the orbit (orbital cellulitis). The causes of preseptal cellulitis include skin trauma (eg, lacerations, insect bites), spread from local infections (eg, hordeolum, dacryocystitis), or systemic infections (eg, upper respiratory tract, middle ear). Clinical features include malaise, fever, and painful eyelid with periorbital edema. Any sign of proptosis, chemosis, painful restricted eye movements, diplopia, lagophthalmos, or optic nerve dysfunction warrants further investigation. Chronic or large hordeola may require incision and curettage.

A recent Cochrane review concluded that there was no evidence of the effectiveness of nonsurgical interventions (including hot or warm compresses, lid scrubs, antibiotics, and steroids) for hordeolum, and controlled clinical trials would be useful.2

Chalazion and hordeolum are similar in appearance and often confused (Table 1). A chalazion is a chronic lipogranuloma due to leakage of sebum from an obstructed meibomian gland. It may develop from an internal hordeolum. Small chalazia usually resolve with time without any intervention, and hot compresses can be effective at encouraging drainage. Persistent lesions may be surgically removed by incision and curettage. Recurrence warrants biopsy and histologic study to rule out sebaceous gland carcinoma.3

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