Treatment Flow for Hordeolum
Antibiotic eye drops (4 times daily): First-line treatment
Severe swelling/redness: Add oral antibiotics (cephalosporins)
Abscess formation without drainage: Perform incision and drainage
Pediatric Hordeolum and Chalazion
1. What are styes and chalazia in children?
Section titled “1. What are styes and chalazia in children?”Definition of stye
Section titled “Definition of stye”A stye is an acute purulent inflammation of the sebaceous glands, sweat glands, or meibomian glands of the eyelid. It occurs when bacteria infect the sebaceous or sweat glands of the eyelid, and can develop on either the skin side or the conjunctival side of the eyelid margin.
External styes, which infect and suppurate the eyelash follicle, Zeis glands (sebaceous glands), or Moll glands (sweat glands), are common, while internal styes, which infect the meibomian glands, are rare. The main causative bacteria are Staphylococcus aureus and Staphylococcus epidermidis. Involvement of CNS (coagulase-negative Staphylococcus), Propionibacterium acnes, and Corynebacterium species, which are normal flora of the conjunctival sac, has also been reported.
Definition of Chalazion
Section titled “Definition of Chalazion”A chalazion is a disease in which secretions become impacted and retained in the meibomian glands, the sebaceous glands of the tarsal plate, leading to a chronic granulomatous inflammation as a foreign body reaction to the degenerated contents. It is a localized inflammatory reaction based on non-infectious meibomian gland obstruction, and its pathophysiology is fundamentally different from that of hordeolum, which is primarily caused by bacterial infection.
According to the Meibomian Gland Dysfunction (MGD) Diagnostic Guidelines, a chalazion is defined as a chronic inflammatory granuloma (lipo-granuloma) caused by meibum stasis, and is considered an important sign of oMGD (meibomianitis) with localized inflammation 1). Chalazion is a localized meibomian gland abnormality and is distinguished from diffuse MGD, but the two are closely related.
Q
What is the difference between a hordeolum and a chalazion?
A
A stye is an acute purulent inflammation caused by bacterial infection, presenting with pain, redness, swelling, and pus point formation. A chalazion is a chronic granulomatous inflammation in response to non-infectious meibomian gland obstruction, presenting as a painless induration in the chronic phase. Acute chalazion may be difficult to distinguish from internal hordeolum. Since the pathophysiology differs, treatment strategies also differ, and accurate differentiation is important.
2. Main symptoms and clinical findings
Section titled “2. Main symptoms and clinical findings”Classification and symptoms of stye
Section titled “Classification and symptoms of stye”| Classification | Infection site | Location of pus point |
|---|---|---|
| External hordeolum | Eyelash follicle, Zeis gland (sebaceous gland), Moll gland (sweat gland) | Skin side |
| Internal hordeolum | Meibomian gland | Conjunctival side |
In the early stage, the eyelid becomes swollen and red, with tenderness at the lid margin. In mild cases, the main complaint is often pain only when blinking. As it progresses, an abscess with a pus plug at the apex (a hard nodule the size of a small bean to a soybean) forms. In external hordeolum, a pus point is observed on the skin side; in internal hordeolum, it is observed on the conjunctival side.
Staging and symptoms of chalazion
Section titled “Staging and symptoms of chalazion”| Stage | Clinical findings | Pain |
|---|---|---|
| Acute phase (acute chalazion) | Eyelid edema, swelling, redness, lipid leakage | Present |
| Chronic phase (chronic chalazion) | Painless nodule (chronic granuloma) the size of a millet seed to a soybean. Located within the tarsal plate, immobile. | None |
In the acute phase, eyelid edema, swelling, redness, and lipid leakage are observed, accompanied by pain. In cases without spontaneous resolution, swelling and redness decrease, but a painless nodule (chronic granuloma) remains in the center of the eyelid. A round, hard mass the size of a millet seed to a soybean is palpable under the eyelid skin, with localized redness and swelling but no spontaneous pain. If the mass enlarges further and ruptures toward the conjunctival side, a polypoid granuloma forms; if it ruptures toward the skin side, granulation tissue becomes exposed on the skin surface.
3. Epidemiology
Section titled “3. Epidemiology”Hordeolum occurs at all ages but is more common in children who have not established hygiene habits. Chalazion tends to occur and recur frequently in children aged 2–8 years. In pediatric ophthalmology clinics, both conditions are among the most common eyelid diseases.
Unlike adults, children have a higher risk of granuloma extending to the skin side due to the fragility of eyelid tissue. Accurate epidemiological data (prevalence, annual incidence, etc.) in children are currently limited, and accumulation of large-scale epidemiological studies remains a challenge.
If infection recurs, evaluation of susceptibility to infection is necessary, and complications of systemic diseases such as diabetes and leukemia should be investigated. Recurrent chalazion is an important clinical sign of childhood blepharokeratoconjunctivitis (BKC), and active investigation for BKC complications is recommended.
In hordeolum, children with skin diseases such as atopic dermatitis and seborrheic dermatitis tend to have a higher frequency of onset. Recurrence of chalazion is often seen when eyelid hygiene and warm compress habits are not established, and home self-care guidance is important for prevention.
4. Diagnosis and Examination Methods
Section titled “4. Diagnosis and Examination Methods”Diagnosis of Hordeolum
Section titled “Diagnosis of Hordeolum”Clinical diagnosis is fundamental. Diagnosis is made based on localized swelling, redness, tenderness, and the presence of a purulent point on the eyelid. In the history, confirm the onset, presence of fever, and any impairment of eye movement to assess progression to orbital cellulitis. If eyelid redness extends beyond the lid margin to the entire skin, or if accompanied by proptosis, impaired eye movement, or high fever, orbital cellulitis is suspected and hospitalization for further examination is indicated.
Differential Diagnosis:
- Chalazion (acute phase) — most difficult to differentiate
- Eyelid tumors and conjunctival tumors
- Intratarsal keratinous cyst of the meibomian gland
- Infectious conjunctivitis
- Orbital cellulitis (severe cases; must be ruled out in children)
Diagnosis of Chalazion
Section titled “Diagnosis of Chalazion”It is characterized by a painless hard nodule under the eyelid skin (located in the tarsal plate, immobile), relatively elastic, and without adhesion to the skin. Chronic chalazion is confirmed by slit-lamp microscopy, assessing the size, mobility, hardness, and adhesion to the skin of the mass. When the conjunctival side is everted, a white or yellowish-white nodule may be observed.
In diagnosing chalazion, acute chalazion (inflammatory phase similar to internal hordeolum) and chronic chalazion (granulomatous phase) are distinguished. In the acute phase, inflammation is controlled with antibiotics and steroids before transitioning to the treatment strategy for the chronic phase.
Differential diagnoses specific to children:
- Eyelid hemangioma (deep) — bluish, soft mass; indistinct borders
- Dacryocystitis — redness and swelling of the lower inner canthus; discharge from punctum upon compression
- Eyelid cellulitis — diffuse swelling and fever; acute inflammation
Q
What should be suspected when chalazion recurs?
A
The possibility of sebaceous gland carcinoma (especially of the upper eyelid) must always be considered in the differential diagnosis, and pathological examination of the excised specimen should be performed. Recurrent chalazion is also an important clinical sign of BKC (childhood blepharokeratoconjunctivitis); therefore, careful examination of the eyelid margin and cornea should be conducted to confirm the presence or absence of BKC. Management of meibomian gland dysfunction (continued guidance on warm compresses and eyelid hygiene) is also important for preventing recurrence.
5. Standard Treatment
Section titled “5. Standard Treatment”Treatment flow for chalazion
Conservative treatment: Warm compresses, antibiotic/steroid eye drops, eyelid hygiene
Local steroid injection: When conservative treatment is ineffective. Cure rate 60–90% (1–2 injections equivalent to excision)
Chalazion excision: Performed when injections are ineffective or the lesion becomes giant. In infants, performed under general anesthesia.
Treatment of Hordeolum
Section titled “Treatment of Hordeolum”Since it is a bacterial infection, antibiotic administration is the mainstay of treatment. In many cases, empirical antibiotics and anti-inflammatory drugs are prescribed.
Eye drops (first-line treatment):
- Bestron® ophthalmic solution 0.5% (cefenoxime) 4 times daily, or
- Cravit® ophthalmic solution 0.5% (levofloxacin) 4 times daily
If swelling and redness are severe, oral antibiotics (cephalosporins) are used in combination. In many cases, the lesion ruptures and drains pus within a few days, but incision may be performed when a pus point appears.
Indications for incision and drainage: When spontaneous drainage does not occur after abscess formation.
- External hordeolum: Incise from the skin side along the eyelid skin crease.
- Internal hordeolum: After everting the eyelid, incise the pus point perpendicular to the eyelid margin.
Conservative treatment of chalazion
Section titled “Conservative treatment of chalazion”In children, surgical procedures have a high threshold because general anesthesia is required, so conservative treatment is attempted first.
Antibacterial eye drops: Used for infection prevention.
Steroid eye drops: Effective, but caution is needed for increased intraocular pressure; use low-concentration preparations.
Warm compresses: Instruct patients to use a commercially available warm eye mask at home twice a day for at least 5 minutes. The MGD clinical practice guidelines strongly recommend warm compresses for improving subjective symptoms and meibum grade in meibomian gland dysfunction 1).
Eyelid hygiene: Perform using a cotton ball moistened with water or a commercially available cleansing agent. The MGD clinical practice guidelines give a weak recommendation for this 1). It is effective when performed after warm compresses.
Steroid Local Injection
Section titled “Steroid Local Injection”Performed when conservative treatment is ineffective.
Triamcinolone acetonide (Kenacort-A® 40 mg/mL, approximately 0.05 mL, i.e., 2 mg) is injected subconjunctivally into the eyelid swelling. Typically, 0.25 to 0.1 mL of triamcinolone is used. The approach is from the conjunctival side to prevent skin depigmentation or hyperpigmentation.
With 1-2 injections, the cure rate is good at 60-90%, and results comparable to chalazion excision have been reported. The time to cure is about 5 days to 2.5 weeks. It is a valuable option for avoiding general anesthesia risks in young children.
Chalazion Excision
Section titled “Chalazion Excision”If conservative treatment fails, early decision for tumor removal should be made. Choose a transconjunctival or transcutaneous approach, and perform incision, curettage, and granuloma removal under infiltration anesthesia with 2% lidocaine hydrochloride. Especially in young children, general anesthesia is often required.
Submit the excised specimen for pathological examination whenever possible (to differentiate sebaceous carcinoma).
Management of Recurrent and Multiple Chalazia
Section titled “Management of Recurrent and Multiple Chalazia”In cases of multiple or recurrent chalazia, topical antibiotic eye drops are used during the acute phase, along with oral antibiotics (cephalosporins). Parents should be continuously instructed to establish a routine of warm compresses and eyelid hygiene to prevent recurrence.
Q
When should a child's chalazion be surgically removed?
A
Surgical removal is considered when conservative treatments (warm compresses, local steroid injections) have been tried sufficiently and have not been effective. However, in children, the anterior eyelid lamella is fragile and granulomas tend to spread toward the skin side; if left untreated and the lesion becomes large, there is an increased risk of tissue loss, tractional scarring, and ectropion. If there is rapid enlargement of the mass or signs of skin necrosis, early removal should be considered. Parents should be informed in advance that general anesthesia is necessary for infants and young children.
6. Pathophysiology and Detailed Mechanism of Onset
Section titled “6. Pathophysiology and Detailed Mechanism of Onset”Pathophysiology of Hordeolum
Section titled “Pathophysiology of Hordeolum”Infection of the eyelid glandular tissue by normal conjunctival flora (coagulase-negative staphylococci, Propionibacterium acnes, Corynebacterium species, staphylococci) causes acute suppurative inflammation. In external hordeolum, infection of the eyelash follicle, Zeis gland, or Moll gland leads to suppuration on the skin side. In internal hordeolum, infection of the meibomian gland leads to suppuration on the conjunctival side.
Pathophysiology of Chalazion
Section titled “Pathophysiology of Chalazion”Meibomian gland secretion is a mixture of cellular debris containing lipids and keratin. When this secretion causes an infarction in the long duct, a foreign body reaction occurs against the accumulated secretion within the gland duct. Inflammation involving epithelioid cells, multinucleated giant cells, and lymphocyte infiltration is triggered, and over time, proliferation of collagen fibers leads to fibrosis and granuloma formation.
Chalazion is also considered a localized form of MGD (meibomian gland dysfunction), and the MGD clinical practice guidelines position it as “an important sign of oMGD (meibomianitis) with localized inflammation” 1). Although it is distinguished from diffuse MGD, the two are closely related conditions.
Special Features of Pathophysiology in Children
Section titled “Special Features of Pathophysiology in Children”In children, the anterior lamella of the eyelid is more fragile than in adults. Therefore, granulomatous inflammation of chalazion tends to infiltrate and spread toward the skin side, and if left untreated, necrosis of the eyelid skin may progress. The larger the formed granuloma, the more extensive the tissue defect of the tarsal plate and orbicularis muscle after excision, increasing the risk of tractional scarring and ectropion as sequelae. This is the rationale for requiring earlier surgical intervention compared to adults.
In infants, the immaturity of the immune system also contributes to the severity of hordeolum. Due to the rich blood supply of the eyelid, local infection may spread beyond the orbital septum into the orbit. If orbital cellulitis develops, inpatient management, intravenous systemic antibiotics, and sometimes surgical drainage are required. Assessment of severity at the first visit and judgment of admission indication are extremely important.
Histopathologically, chalazion forms a lipogranuloma with accumulation of epithelioid cells, multinucleated giant cells, and lymphocytes. Pathological differentiation from sebaceous carcinoma is essential, and in recurrent cases, it is desirable to submit all pathological specimens to a specialized pathologist.
7. Latest Research and Future Perspectives
Section titled “7. Latest Research and Future Perspectives”IPL (Intense Pulsed Light) Therapy
Section titled “IPL (Intense Pulsed Light) Therapy”IPL therapy has been reported to be effective for adult MGD. There are limited reports suggesting it may be superior to conventional warm compresses for chalazion treatment in pediatric BKC, but evidence for its use in children is currently insufficient. Further investigation is needed.
Meibum Expression Therapy
Section titled “Meibum Expression Therapy”The MGD clinical practice guidelines weakly recommend meibum expression using compression forceps as a treatment option for obstructive MGD 1). It is also expected to be applied in the future for the prevention and recurrence of chalazia.
Painless Procedure Using Topical Anesthetic Cream
Section titled “Painless Procedure Using Topical Anesthetic Cream”Efforts to reduce pain during pediatric chalazion procedures using topical anesthetic creams such as EMLA have been reported, but evidence is currently limited.
Molecular Pathological Research
Section titled “Molecular Pathological Research”Analysis of inflammatory cytokine profiles involved in granuloma formation in chalazion is progressing. Elucidation of the molecular relationship with MGD and BKC is expected to lead to advances in prevention and treatment strategies for chalazion in children.
8. Prognosis and Course
Section titled “8. Prognosis and Course”Prognosis of Hordeolum
Section titled “Prognosis of Hordeolum”Most cases respond well to medical and surgical treatment and heal without sequelae. If severe inflammation persists or recurs, redness or a mass may remain on the eyelid margin. If treatment is delayed, appropriate measures are not taken, or a meibomian gland cyst becomes infected, it can progress to eyelid or orbital cellulitis. If infection recurs, consider immunocompromised states and investigate systemic diseases such as diabetes mellitus or leukemia.
For recurrent hordeolum, early treatment of BKC (childhood blepharokeratoconjunctivitis) may reduce the frequency of recurrence. Continuous management of meibomianitis improves prognosis.
Prognosis of Chalazion
Section titled “Prognosis of Chalazion”The success rate of conservative therapy is reported to be around 80% in many studies. However, in cases where the mass has become fibrotic, it is difficult to completely remove the eyelid induration. The prognosis after surgical treatment is generally good, but if collagen fibers are not sufficiently dissected, postoperative induration may persist and lead to patient complaints.
The cure rate of local steroid injection is good at 60-90% with 1-2 injections, and it is worth actively trying first in infants at risk for general anesthesia.
In children, the larger the granuloma, the more extensive the tissue defect after excision, increasing the risk of tractional scarring and ectropion. If conservative treatment is ineffective, it is important to decide on early excision. After excision, continue to instruct on warm compresses and eyelid hygiene to prevent recurrence. If BKC is found to be present, treat it concurrently to aim for normalization of meibomian gland function.
Q
How should warm compresses be performed?
A
Use a commercially available disposable warm eye mask, applying it to the eyes for at least 5 minutes twice a day. The heat melts the lipids in the meibomian glands, promoting their excretion from the ducts. Combining with eyelid hygiene is even more effective. Continuation is important, and it is desirable to guide caregivers to make it a habit.
9. References
Section titled “9. References”- マイボーム腺機能不全診療ガイドライン作成委員会. マイボーム腺機能不全診療ガイドライン. 日眼会誌. 2023;127(2):109-146.
- Shin HJ, Yoon JS, Choung H, Lew H. Management Practice for Hordeolum and Chalazion: A Survey of the Korean Society of Ophthalmic Plastic and Reconstructive Surgery (KSOPRS) Members. Korean J Ophthalmol. 2025;39(3):222-240. PMID: 40267992.
- Ozer PA, Gurkan A, Kurtul BE, Kabatas EU, Beken S. Comparative Clinical Outcomes of Pediatric Patients Presenting With Eyelid Nodules of Idiopathic Facial Aseptic Granuloma, Hordeola, and Chalazia. J Pediatr Ophthalmol Strabismus. 2016;53(4):206-11. PMID: 27182747.