Changes

October 2024 — reviewed. A literature search was conducted in July 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to the recommendations have been made.

Update

Goals

To support primary healthcare professionals to:

• Make a diagnosis of a stye. 
• Offer appropriate self-care advice.
• Provide pharmacological treatment when appropriate.
• Identify and refer people who need specialist management.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

NICE quality standards

What is it?

• A stye (or hordeolum) is an acute, localized infection or inflammation of the apocrine or sebaceous glands of the eyelid. They are usually caused by a staphylococcal infection and can be external (more common) or internal.
  
  • External styes affect the eyelash follicle and its associated gland of Zeis or Moll.
  • Internal styes affect the Meibomian (oil) glands (located within the tarsal plate in the eyelid).

[College of Optometrists, 2022]

How common is it?

• The incidence of styes is unknown, but they are commonly seen in clinical practice.
  
  • There are no known differences in prevalence between populations worldwide, and there are no known differences between sexes or races.
  • Styes can occur at any age but are more common in adults than children.

[BMJ, 2023]

What are the risk factors?

• Risk factors for styes include:
  • Poor eyelid hygiene.
  • Chronic blepharitis. See the CKS topic on Blepharitis for more information.
  • Acne rosacea. See the CKS topic on Rosacea - acne for more information.
  • Elevated serum cholesterol — may increase the risk of blockage to sebaceous glands of the eyelids, predisposing to styes. 
  • Decreased immunity due to certain systemic diseases, such as diabetes. See the CKS topics on Diabetes - type 1 and Diabetes - type 2 for more information.

[Yanoff and Duker, 2013; Sun, 2019; College of Optometrists, 2022; BMJ, 2023]

What is the prognosis?

• Styes are usually self-limiting, with symptoms resolving within 5 to 7 days. However, recurrence is common in people with persistent risk factors.

[Yanoff and Duker, 2013; Carlisle, 2015; College of Optometrists, 2022; BMJ, 2023]

What are the complications?

• Complications of a stye include:
  • Infective conjunctivitis — infection of the eyelid margin can spread, leading to inflammation of the conjunctiva. See the CKS topic on Conjunctivitis - infective for more information.
  • Meibomian cyst — a persistent internal stye may develop into a meibomian cyst, which is a chronic, non-infectious, inflammatory granuloma caused by blockage of meibomian gland duct(s). See the CKS topic on Meibomian cyst (chalazion) for more information.
  • Cellulitis — an untreated stye can lead to localized cellulitis of the eyelid and surrounding skin. This may develop into: 
    • Periorbital cellulitis — infection of tissues lying in front of the orbital septum (therefore, not an orbital condition). It typically presents with an acute onset of swelling, redness, and tenderness of the lids. However, it does not cause visual impairment, limited or painful eye movements, oedema of the conjunctiva, or eyeball protrusion. There may be associated fever and malaise.
    • Orbital cellulitis (rare) — infection of tissues lying behind the orbital septum (within the orbit). It presents with an acute onset of unilateral eyelid swelling, with a red and painful eye. It is often associated with severe pain, blurred or double vision, limited and painful eye movements, eyeball protrusion, headache, fever, and malaise. It is a medical emergency that can progress rapidly, potentially causing vision loss and serious complications, such as meningitis or a cerebral abscess.

[Yanoff and Duker, 2013; Carlisle, 2015; College of Optometrists, 2022; BMJ, 2023; College of Optometrists, 2024]

How should I diagnose a stye?

The diagnosis of a stye is usually based on history and clinical examination. 

• Take history.
  • Ask about the symptoms experienced.
    • Typical symptoms of styes include a tender lump in the eyelid, excessive tearing (epiphora), and local redness of the eye and lid.
    • Symptoms are usually unilateral but may be bilateral.
  • Enquire about:
    • Risk factors, such as chronic blepharitis, acne rosacea, and diabetes.
    • Exacerbating factors, such as makeup, fragrances, hair care products, or contact lens use.
    • Previous episodes of styes.
    • Previous history of eye trauma or surgery.
• Examine the eye.
  • Look for typical signs of styes.
    
    • An external stye presents as a tender, inflamed swelling of the eyelid margin, usually around an eyelash follicle. The swelling may point anteriorly through the skin. Occasionally, there may be multiple abscesses involving the entire eyelid.
    • An internal stye presents as a tender, inflamed swelling of the external eyelid. It is usually more painful and located further from the lid margin than an external stye. When the eyelid is everted, a localized swelling of the tarsal plate is visible. The swelling may point anteriorly through the skin or posteriorly through the conjunctiva.
  • Look for signs of:
    • Risk factors, such as chronic blepharitis.
    • Complications, such as infective conjunctivitis.
    • Differential diagnoses, such as acute dacryocystitis.
  • Look for features of a serious underlying condition, such as:
    
    • A firm, warm, tender, erythematous, oedematous eyelid associated with severe pain, blurred/double vision, limited and painful eye movements, headache, fever, and malaise — suggestive of associated orbital cellulitis. 
    • Atypical clinical features, such as distortion of the eyelid margin, lash loss, ulceration, bleeding, or marked inflammation — suggestive of possible eyelid cancer.
    • Chronic or recurrent lesions in the same location (especially in older people) — suggestive of possible sebaceous gland carcinoma.
• Investigations are not routinely required but may be needed to exclude a risk factor, complication, or differential diagnosis.

What else might it be?

• Differential diagnoses of styes include:
  • Blepharitis  — a chronic inflammatory condition affecting the eyelid margin. Chronic blepharitis is a risk factor for styes. See the CKS topic on Blepharitis for more information.
  • Benign eyelid cysts, such as:
    • Meibomian cyst (chalazion) — a chronic, non-infectious, inflammatory granuloma caused by blockage of meibomian gland duct(s). See the CKS topic on Meibomian cyst (chalazion) for more information.
    • Cysts of Moll — arise from blocked apocrine sweat glands on the eyelid margin. They are typically dome-shaped papules or nodules filled with clear fluid.
    • Cysts of Zeis — arise from blocked sebaceous glands on the eyelid margin. They are typically filled with yellow oily secretions.
    • Epidermal inclusion cysts — arise from occlusion of the infundibulum of the hair follicle. They are typically slow-growing, firm, elevated, round lesions with a central pore filled with keratin.
  • Dacryocystitis — inflammation or infection of the lacrimal sac, often caused by blockage of the nasolacrimal duct. Symptoms include pain and swelling in the inner corner of the eye, redness, purulent discharge, and excessive tearing. 
  • Dacryoadenitis — inflammation or infection of the lacrimal (tear) gland. Symptoms include pain and swelling in the upper outer eyelid, redness, and possible tearing and discharge from the eye. The condition can be acute or chronic and may result from infection, autoimmune disease, or other underlying health conditions.
  • Periorbital cellulitis — infection of tissues lying in front of the orbital septum (therefore, not an orbital condition). It typically presents with an acute onset of swelling, redness, and tenderness of the lids. However, it does not cause visual impairment, limited or painful eye movements, oedema of the conjunctiva, or eyeball protrusion. There may be associated fever and malaise.
  • Benign eyelid tumours — actinic keratosis, squamous cell papilloma, sebaceous gland hyperplasia, haemangioma, and pyogenic granuloma.
  • Malignant eyelid tumours — basal cell carcinoma, squamous cell carcinoma, and melanoma are the most frequently encountered malignant tumours involving the eyelids. Sebaceous gland carcinoma is a rare and aggressive tumour most commonly found on the eyelids but can develop in any sebaceous gland.
    • Eyelid cancer should be suspected in people with atypical, unilateral, inflammatory eyelid disease that is unresponsive to treatment.
    • Features such as eyelid distortion, nodular mass, ulceration, bleeding, extensive scarring, lash loss, localized crusting and scaling of the dermis, or yellow conjunctival nodules surrounded by intense inflammation may suggest the presence of eyelid cancer. For information on the recognition and referral of suspected skin cancers, see the CKS topic on Skin cancers - recognition and referral.
    • Sebaceous cell carcinoma should be considered in people with chronic or recurrent lesions in the same location, particularly older people.

Scenario: Management

From age 1 month onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of styes (hordeola).

Search dates

September 2019 - July 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 11th September 2019). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S3    S1 OR S2 
S2    AB ( stye or styes or hordeola or hordeolum ) OR TI ( stye or styes or hordeola or hordeolum ) 
S1    (MH "Hordeolum") 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.