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Referral and warning signs
When to refer
Refer if: Large size, Significant pain/swelling, Associated preseptal cellulitis, Not resolving after 1-2 weeks, Recurrent styes, Vision affected (rare).
Red flags
- Diffuse eyelid swelling and redness extending beyond localized lesion (preseptal cellulitis).
- Proptosis (bulging eye) or pain with eye movements (suggests orbital cellulitis - emergency).
- Visual changes.
- Lesion that looks suspicious for malignancy (persistent, loss of lashes).
Signs and symptoms
- Localized, tender, red swelling on the eyelid margin (external) or within the eyelid (internal).
- May start with itching.
- Pain and tenderness.
- Often points and develops a small pustule ('head').
- May burst spontaneously, releasing pus.
- Mild eyelid swelling.
- Tearing.
Risk factors
- Poor eyelid hygiene.
- Blepharitis (chronic eyelid inflammation).
- Rubbing eyes.
- Contact lens use.
- Stress.
Diagnosis
Clinical assessment
Diagnosis based on characteristic appearance of a localized, tender, red lump on the eyelid margin or within the eyelid, often with a visible pus point.
Investigations
- Usually clinical diagnosis only.
Differential diagnosis
- Chalazion (chronic, non-tender granuloma of Meibomian gland).
- Blepharitis (generalized inflammation of lid margins).
- Preseptal cellulitis (more diffuse eyelid swelling/redness).
- Sebaceous gland carcinoma (rare, persistent or recurrent lesion).
Management
Non-pharmacological management
- Warm Compresses: Apply clean, warm compress to the affected eyelid for 5-10 minutes, 3-4 times daily. Promotes drainage.
- Lid Hygiene: Gentle cleaning of eyelid margins.
- Avoid Rubbing Eye.
- Epilation: Remove the associated eyelash if it is loose and at the centre of the pustule (may facilitate drainage).
Pharmacological treatment
- Topical Antibiotic Ointment: Tetracycline eye ointment 1% applied to the eyelid margin 2-4 times daily until resolved + 2 days. May help prevent spread but limited effect on established lesion. (LOC: HC2)
- Systemic Antibiotics: Rarely needed unless associated preseptal cellulitis develops.
Monitoring
Usually self-limiting, resolves in 1-2 weeks. Follow up if not improving or worsening.
Complications
- Usually resolve without complications.
- Preseptal cellulitis (spread of infection to surrounding eyelid tissue).
- Recurrence.
- Chalazion formation (if internal hordeolum doesn't drain completely).
Prevention
- Good eyelid hygiene (regular cleaning if prone).
- Avoid rubbing eyes.
- Manage blepharitis if present.
Patient education
- Reassurance that it's a common, usually benign infection.
- How to apply warm compresses.
- Importance of hygiene, avoid rubbing/squeezing.
- How to apply antibiotic ointment if prescribed.
- When to return if not improving or worsening.
Uganda-specific notes
Common condition. Managed primarily with warm compresses and hygiene. Tetracycline eye ointment widely available.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 20, Section 20.1.3