Hordeolum
It is an acute focal infection (usually staphylococcal) involving either
the glands of Zeis (external hordeola, or styes) or, less frequently,
the meibomian glands (internal hordeola)
Pathophysiology
There is usually underlying meibomitis with thickening and stasis of gland
secretions with resultant inspissation of the Zeis or meibomian gland
orifices. Stasis of the secretions leads to secondary infection, usually
by Staphylococcus aureus. [3] Histologically, hordeola represent focal
collections of polymorphonuclear leukocytes and necrotic debris (ie, an
abscess).
Essentially, a hordeolum represents an acute focal infectious
process, while a chalazion represents a chronic, noninfectious
granulomatous reaction. However, chalazia often evolve from
internal hordeola
Epidemiology
Frequency
United States
Hordeola are common in clinical practice, but no data are available on the
precise incidence and prevalence in the United States.
International
No data are available on the incidence and prevalence of hordeola
internationally.
Race
There is no known racial predilection to developing hordeola.
Sex
There is no sexual predilection to developing hordeola. Both men and women seem
to be equally affected.
Age
Hordeola are more common in adults than in children, possibly because of a
combination of higher androgenic levels (and increased viscosity of sebum), higher
incidence of meibomitis, and rosacea in adults. However, hordeola can occur in
children.
Clinical Presentation
History
Hordeola essentially represent focal abscesses; therefore, they will present
with features of acute inflammation, such as a painful, warm, swollen, red
lump on the eyelid.
The eyelid lump may also induce corneal astigmatism and cause blurring of
vision.
The patient often has a past history of similar eyelid lesions or risk
factors for hordeola, such as meibomian gland dysfunction,
blepharitis, or rosacea.
Physical
On examination, a tender erythematous subcutaneous nodule is present
near the eyelid margin, which may undergo spontaneous rupture and
drainage. If sufficient edema is present, then it may be difficult to palpate a
discrete nodule. These nodules may be unilateral or bilateral, single or
multiple.
The inflammation associated with hordeola may spread to adjacent tissue
and cause a secondary preseptal cellulitis.
Causes
Hordeola are associated with S aureus infection. [3]
Patients with chronic blepharitis, meibomian gland dysfunction, and ocular
rosacea are at greater risk of developing hordeola than the general
population.
Workup
Laboratory Studies
The diagnosis is based on history and clinical examination, and cultures
are not indicated in uncomplicated cases.
Histologic Findings
Histopathology of a hordeolum reveals an abscess or a focal collection of
polymorphonuclear leukocytes and necrotic tissue.
Histologically, chalazia represent a lipogranulomatous inflammatory
reaction.
Basal cell carcinoma 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 & Management
Medical Care
Hordeola are usually self-limited, spontaneously improving in 1-2 weeks.
Medical therapy for hordeola includes eyelid hygiene (lid scrubs), warm
compresses and massages of the lesions for 10 minutes 4 times per day,
and topical antibiotic ointment in the inferior fornix if the lesion is draining or
if there is an accompanying blepharoconjunctivitis. [9, 10] Nonsurgical
remedies for hordeolum, although unproven, [11] do not seem to be harmful.
If an external hordeolum is centered around a lash follicle, the lash
can be pulled to enhance drainage.
Systemic antibiotics may be indicated if the hordeola is complicated
by preseptal cellulitis. Oral doxycycline may also be added if there
is a history of multiple or recurrent lesions or if there is significant
and chronic meibomitis.
Internal hordeola may occasionally evolve into chalazia, which may
require topical steroids, intralesional steroids, or surgical incision
and curettage.
Surgical Care
Incision and drainage is indicated if the hordeolum is large or if it is
refractory to medical therapy.
Incision and drainage is done under local anesthesia, and the incision is
made through the skin and orbicularis (in the case of external hordeola) or
through the tarsal conjunctiva and tarsus (in the case of internal hordeola).
The specimen should be sent for histopathological evaluation to confirm the
diagnosis and to rule out a more sinister pathology (eg, basal cell
carcinoma).
Medication Summary
The goals of pharmacotherapy are to treat the infection, to reduce
morbidity, and to prevent complications.
Antibiotics
Class Summary
A course of oral antibiotics is indicated if the hordeolum is complicated by
preseptal cellulitis.
Erythromycin base (Ery-Tab, PCE, E.E.S. 400)
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Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from
ribosomes, causing RNA-dependent protein synthesis to arrest.
Indicated for infections caused by susceptible strains of microorganisms and for
prevention of corneal and conjunctival infections.
Dosage Forms & Strengths
tablet
250mg
500mg
Dose Range
Usual dosage range: 250-500 mg PO q6-12hr or 500 mg q12hr or 333 mg PO q8hr
Severe infections: Up to 4 g/day
Take on empty stomach if possible; PCE Dispertab may be taken with food; base
has poorest absorption
Pediatric
Dosage Forms & Strengths
tablet
250mg
500mg
Dose Range
Mild to moderate infection: 30-50 mg/kg/day PO divided q6-12hr; not to exceed 2
g/day
Severe infection: 15-50 mg/kg/day PO ; not to exceed 4 g/day
Amoxicillin/clavulanate (Augmentin, Augmentin ES-600, Augmentin XR,
Amoclan)
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Amoxicillin inhibits bacterial cell wall synthesis by binding to penicillin-binding
proteins. Addition of clavulanate inhibits beta-lactamaseproducing bacteria. Good
alternative antibiotic for patients allergic to or intolerant to macrolides. Usually is well
tolerated and provides good coverage for most infectious agents.
Doxycycline (Morgidox, Adoxa, Oracea)
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Doxycycline inhibits protein synthesis and, therefore, bacterial growth by binding with
30S and possibly 50S ribosomal subunits of susceptible bacteria. May be added if
there is history of multiple or recurrent lesions or if there is significant and chronic
meibomitis.
Adult
Dosage Forms & Strengths
capsule
50mg (Monodox, generic)
75mg (Monodox)
100mg (Monodox, Vibramycin, generic)
150mg (Adoxa)
solution, reconstituted powder for IV
100mg (Doxy, generic)
syrup
50mg/5mL (Vibramycin)
oral suspension
25mg/5mL (Vibramycin, generic)
tablet
20mg (generic)
50mg (Adoxa, generic)
75mg (Acticlate, Adoxa, generic)
100mg (Adoxa, generic)
150mg (Acticlate, generic)
tablet, delayed-release
50mg (Doryx)
60mg (Doryx MPC)
75mg (generic)
100mg (generic)
120mg (Doryx MPC)
150mg (Doryx, generic)
200mg (Doryx)
capsule, delayed-release
40mg (Oracea, generic)
periodontal extended-release liquid
10%
General Dosage
Initial: 200 mg/day divided twice daily PO/IV on first day (IV may be given
qDay), THEN
Maintenance: 100-200 mg/day qDay or divided q12hr PO/IV (IV may be
given qDay)
Doryx MPC
Mild to moderate infections: 240 mg PO divided q12hr on first day of
treatment
Maintenance: 120 mg PO qDay; in the management of more severe
infections (particularly chronic infections of the urinary tract), 120 mg
q12hr recommended
Specific Bacterial Infections
Typical dosage and frequency: 100 PO q12hr on day 1, then 100 mg PO
qDay
Severe infections (particularly chronic infections of the urinary tract): 100
mg q12hr is recommended
Doryx MPC
240 mg/day divided twice daily PO on first day; THEN
Maintenance: 120 mg PO qDay; for more severe infections
administer BID (particularly chronic UTI)
Bartonella bacilliformis
Bacillary angiomatosis, peliosis hepatitis, bacteremia, or
osteomyelitis: 100 mg PO q12hr
CNS infections: 100 mg q12 hr PO/IV with or without rifampin 300 mg
PO/IV q12hr
Equivalent dose of Doryx MPC: 120 mg PO BID
Brucellosis
Brucellosis due to Brucella species
100 mg PO twice daily for 6 weeks with rifampin or streptomycin
Equivalent dose of Doryx MPC: 120 mg PO BID
Cholera
Indicated for cholera caused by Vibrio cholerae
300 mg PO once; adjunct to fluid and electrolyte replacement
Equivalent dose of Doryx MPC is 360 mg PO
Other infections include
Relapsing fever due to Borrelia recurrentis
Plague due to Yersinia pestis
Tularemia due to Francisella tularensis
Campylobacter fetus infections caused by Campylobacter fetus
Gram-negative bacteria
Because many strains of the following groups of microorganisms
have been shown to be resistant to doxycycline, culture and
susceptibility testing are recommended
Escherichia coli
Enterobacter aerogenes
Shigella species
Acinetobacter species
Urinary tract infections caused by Klebsiella species
Infections when Penicillin is Contraindicated
When penicillin is contraindicated, doxycycline is an alternative drug in the
treatment of the following infections:
-Syphilis caused by Treponema pallidum
-Yaws caused by Treponema pallidum subspecies pertenue
-Listeriosis due to Listeria monocytogenes
-Vincents infection caused by Fusobacterium fusiforme
-Actinomycosis caused by Actinomyces israelii
-Infections caused by Clostridium species
Acute Bacteria Rhinosinusitis
200 mg/day PO qDay or divided BID for 5-7 days
Respiratory Tract Infections
100 PO q12hr on day 1, then 100 mg PO qDay
Doryx MPC: 120 mg PO q12hr on day 1, then 120 mg PO qDay
Respiratory infections
Respiratory tract infections caused by Mycoplasma pneumoniae
Psittacosis (ornithosis) caused by Chlamydophila psittaci
Indicated for the following microorganisms, when bacteriological
testing indicates appropriate susceptibility to doxycycline:
-RTIs caused by Haemophilus influenzae
-RTIs caused by Klebsiella species
-Upper RTIs caused by Streptococcus pneumoniae
Sexually Transmitted Diseases
CDC STD guidelines: MMWR Recomm Rep. June 5, 2015:64(RR3);1-137
Uncomplicated gonococcal infection of the cervix, urethra, and rectum:
Ceftriaxone 250 mg IM once plus azithromycin 1 g PO once (preferred) or
alternatively doxycycline 100 mg PO q12hr for 7 days
Uncomplicated urethral, endocervical, or rectal infection caused by
Chlamydia trachomatis: 100 mg PO BID x 7 days
Nongonococcal urethritis caused by C. trachomatis and U. urealyticum: 100
mg PO BID x 7 days
Syphilis (early): Patients who are allergic to penicillin should be treated with
doxycycline 100 mg PO BID x 2 weeks
Syphilis >1 year duration: Patients who are allergic to penicillin should be
treated with doxycycline 100 mg PO BID x 4 weeks
Acute epididymo-orchitis caused by N. gonorrhoeae or C trachomatis: 100
mg PO BID x least 10 days
Equivalent dose of Doryx MPC is 120 mg PO BID
Periodontal Disease
100-200 mg PO qDay
Atridox: Apply subgingivally; dose depends on size, shape, and number of
pockets treated
Rosacea
Oracea: 40 mg PO qAM; on an empty stomach
Chlamydia trachomatis
Trachoma caused by Chlamydia trachomatis, although the infectious agent
is not always eliminated as judged by immunofluorescence; also approved
for inclusion conjunctivitis caused by chlamydia trachomatis
100 PO q12hr on day 1, then 100 mg PO qDay
Equivalent dose of Doryx MPC is 120 mg PO q12h on day 1, then 120 mg
PO qDay
Anthrax
Postexposure prophylaxis: 100 mg PO BID for 60 days
Equivalent dose of Doryx MPC is 120 mg PO BID for 60 days
Malaria
Indicated for prophylaxis of malaria due to Plasmodium falciparum in shortterm travelers (ie, <4 months) to areas with chloroquine and/or
pyrimethamine-sulfadoxine resistant strain
Prophylaxis: 100 mg PO qDay; begin taking 1-2 days before travel and
continue daily during travel and for 4 weeks after traveler leaves malaria
infested area
Severe infection (off-label): 100 mg PO/IV q12hr x 7 days with 3-7 days
quinidine gluconate
Uncomplicated infection (off-label): 100 mg PO q12hr x 7 days with 3-7
days quinine sulfate depending on region
Equivalent dose of Doryx MPC is 120 mg
Intestinal Amebiasis
Indicated for adjunctive therapy to amebicides for acute intestinal
amebiasis
100 PO q12hr on day 1, then 100 mg PO qDay
Equivalent dose of Doryx MPC is 120 mg PO q12h on day 1, then 120 mg
PO qDay
Rickettsial Infections
Indicated for Rocky Mountain spotted fever, typhus fever and the typhus
group, Q fever, rickettsial pox, and tick fevers caused by Rickettsiae
100 PO q12hr on day 1, then 100 mg PO qDay
Equivalent dose of Doryx MPC is 120 mg PO q12h on day 1, then 120 mg
PO qDay
Infective Endocarditis
Suspected Bartonella infection with a negative culture: 100 mg PO BID x 6
weeks in combination with gentamicin and ceftriaxone
Positive culture Bartonella infection: 100 mg PO BID x 6 weeks in
combination with gentamicin or rifampin
Equivalent dose of Doryx MPC is 120 mg PO BID
Purulent Cellulitis from Community Acquired MRSA (Off-label)
100 mg PO q12hr for 5-10 days
Pediatric
Dosage Forms & Strengths
capsule
50mg (Monodox, generic)
75mg (Monodox)
100mg (Monodox, Vibramycin, generic)
150mg (Adoxa)
solution, reconstituted powder for IV
100mg (Doxy, generic)
syrup
50mg/5mL (Vibramycin)
oral suspension
25mg/5mL (Vibramycin, generic)
tablet
20mg (generic)
50mg (Adoxa, generic)
75mg (Acticlate, Adoxa, generic)
100mg (Adoxa, generic)
150mg (Acticlate, generic)
tablet, delayed-release
50mg (Doryx)
60mg (Doryx MPC)
75mg (generic)
100mg (generic)
120mg (Doryx MPC)
150mg (Doryx, generic)
200mg (Doryx)
capsule, delayed-release
40mg (Oracea, generic)
General Dosing Guidelines
8 years: Not recommended for midle-to-moderate infections; may cause
tooth discoloration and enamel hypoplasia during tooth development
>8 years, <45 Kg
Load: 4.4 mg/kg/day PO/IV divided q12hr day 1
Maintenance: 2.2-4.4 mg/kg/day IV/PO qDay (may divide BID for
higher doses)
Doryx MPC
o
Severe or life-threatening infections (eg, anthrax, Rocky
Mountain spotted fever): 2.6 mg/kg PO BID
o
Less severe infections: 5.3 mg/kg PO divided into 2 doses on
day 1, then a maintenance dose of 2.6 mg/kg PO qDay
>8 years, 45 kg
100 mg PO q12hr or 50 mg PO q6hr on day 1, followed by
maintenance dose of 100 mg/day as single dose or as 50 mg q12hr
Doryx MPC: Doryx MPC: 120 mg PO q12h on day 1, followed by
maintenance dose of 120 mg/day; may increase frequency to q12hr for
more severe infections, particularly chronic UTI
Anthrax
Postexposure prophylaxis
8 years: 2.2 mg/kg PO/IV q12hr for 60 days (change to amoxicillin as
soon as penicillin susceptibility confirmed)
>8 years (45kg): 2.2 mg/kg PO/IV q12hr for 60 days (Doryx MPC: 2.6
mg/kg PO q12hr for 60 days)
>8 years (>45kg): 100 mg PO/IV q12hr for 60 days (Doryx MPC: 120 mg
PO q12hr for 60 days)
Malaria
>8 years
Prophylaxis
2 mg/kg PO qDay; not to exceed 100 mg /day
Doryx MPC: 2.4 mg/kg PO qDay
Initiate treatment 1-2 days prior to travel to endemic area and
continue for 4 weeks after leaving the area
Severe infection
<45 kg: 2.2 mg/kg q12hr for 7 days with quinidine gluconate
45 kg (Off label): 100 mg PO/IV q12hr for 7 days with quinidine
gluconate
Uncomplicated
>8 years: 2.2 mg/kg; not to exceed 100 mg dose PO q12hr for 7 days
with quinine sulfate
Tularemia
<45 kg: 2.2 mg/kg PO twice daily for 14-21 days
45 kg: 100 mg PO twice daily for 14-21 days
Cholera
Single dose: 7 mg/kg PO/IV; not to exceed 300 mg/dose; adjunct to fluid
and electrolyte replacement
Multiple dose: 2 mg/kg PO/IV twice daily on day 1; THEN, 2 mg/kg qDay on
days 2 and 3; not to exceed 100 mg/dose; adjunct to fluid and electrolyte
replacement
Follow-up
Further Outpatient Care
Patients should be followed within 2-4 weeks of institution of medical
therapy to assess response to therapy and need for surgical incision and
curettage.
Deterrence/Prevention
Try to prevent recurrences by minimizing or eliminating risk factors, such as
blepharitis and meibomian gland dysfunction, through daily lid hygiene and
warm compresses.
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
Hordeola are usually self-limited and spontaneously resolve within 1-2
weeks. The resolution is hastened with the use of warm compresses and
lid hygiene.
Internal hordeola may occasionally evolve into chalazia, which may require
topical or intralesional steroids or even incision and curettage.
