Prescribe oral antibiotics when internal hordeola do not respond to topical therapy

A. Skip topical therapy, choose orals

Elizabeth D. Muckley, OD, FAAO
Elizabeth D. Muckley

Elizabeth D. Muckley, OD, FAAO: An internal hordeolum is a bacterial infection of one of the meibomian glands in the eyelid. Patients complain of a tender or painful nodule. Staphylococcus species are usually the most common bacteria to infect the glands. In some cases, the infection can spread to the soft tissue of the eyelid and cause a preseptal cellulitis. After the infection resolves, chronic inflammation can often persist and cause a granulomatous chalazion. The primary difference between a chalazion and hordeolum is that chalazia are a result of inflammation and hordeola or styes are infectious. The symptom of pain typically points to hordeolum.

In this case, the patient has a painful hordeolum. Hot compresses and topical antibiotic/steroids (conservative therapy) were initiated, but the patient’s symptoms persisted. I am not surprised that conventional treatment did not work. Oftentimes, topical treatment does not penetrate the lid tissue effectively when it is an internal hordeolum. Due to this ineffectiveness, many clinicians are now skipping traditional, topical therapy and going right to oral antibiotics.

Because our patient was still complaining of pain with lid erythema and edema, I would recommend an oral antibiotic. Antibiotic therapy could be amoxicillin, Keflex (cephalexin, Dista), doxycycline or erythromycin. I typically use 500 mg of Augmentin (amoxicillin/clavulanate, SK Beecham) twice daily for 7 to 10 days. This has a good spectrum of coverage and is also indicated for preseptal cellulitis. In addition, the twice daily dosing is far easier for patients to comply with than an antibiotic dosed four times a day.

Steroid injection or excision while a hordeolum is “hot” or actively infected is not recommended for obvious reasons. If you can visibly see a “white head” or area of purulent material, I would recommend expression of this material in office. Expression with massage coupled with an oral antibiotic will expedite resolution, and patients show improvement within 24 hours. I counsel patients to continue hot compresses to help with the pain and tenderness. An old remedy of using a warm, hard-boiled egg or potato to apply moist heat works well for pain relief.

At the return visit, if our patient’s pain and erythema was resolved but a lump remained, then we now have a granulomatous chalazion. Chalazia respond well to steroid (Kenalog, triamcinolone acetate, Bristol-Myers Squibb) injections because the material usually consists of neutrophils, lymphocytes and plasma cells.

Kenalog injections are not without some risk. They are contraindicated for individuals with dark skin because depigmentation can occur afterwards and may be permanent. Chalazia excision and curettage is another option, especially if they are large or are present for months.

For more information:
  • Elizabeth D. Muckley, OD, FAAO, can be reached at Northeast Ohio Eye Surgeons, 2013 State Rt. 59, Kent, OH 44240; (330) 678-0201; e-mail: dredm1@aol.com. Dr. Muckley has no direct financial interest in the products she mentions, nor is she a paid consultant for any companies she mentions.

A. Early oral treatment

Tammy P. Than, MS, OD, FAAO
Tammy P. Than

Tammy P. Than, MS, OD, FAAO: I start oral treatment early on when a patient has an internal hordeolum. Because this is an infection located within the meibomian glands, it is often difficult to achieve resolution without systemic management. If an internal hordeolum fails to resolve, it may advance to preseptal cellulitis or result in a chalazion once the infection is gone. Therefore, I manage these early with oral antibiotics, often at the initial visit. Topical antibiotics have a difficult time penetrating the meibomian glands, so I will only include a topical antibiotic in the treatment regimen if there is evidence of drainage.

Assuming that the patient has no allergies or other medical history that precludes their use, I will prescribe dicloxacillin 125 mg to 250 mg four times daily for 10 days or cephalexin 250 mg four times daily for 10 days. These oral medications have been available for a long time but are still effective for soft tissue infections associated with the eye. They are inexpensive and most patients will have been exposed to them before, so tolerability should already be proven. A relatively new Keflex 750 mg can be taken twice daily, but it is not available generically and is significantly more expensive.

I will have the patient continue with warm compresses and return for follow-up in 3 to 5 days or sooner if the condition worsens. Once the pain is gone, if a mass is still present, I will have the patient begin digital massage following the warm compresses two to four times a day.

For more information:
  • Tammy P. Than, MS, OD, FAAO, is a staff optometrist at Carl Vinson VAMC/Eye Clinic. She can be reached at 458 Fairfield Dr., Dublin, GA 31021; (478) 272-1210, ext. 3341; fax: (478) 277-2706; e-mail: tammythan@bellsouth.net. Dr. Than has no direct financial interest in the products she mentions, nor is she a paid consultant for any companies she mentions.

A. Compliance low with topicals, prescribe orals

Gary E. Oliver, OD
Gary E. Oliver

Gary E. Oliver, OD: Patients with internal hordeola frequently are nonresponsive to hot compresses and topical antibiotic/steroid agents for several reasons. The patient may not be aggressive enough with the physical treatment and only use the hot compresses for a few minutes a day, therefore minimizing the benefits. A second reason is that topical drops may not sufficiently penetrate the internal hordeolum site to reach therapeutic levels.

When a patient is nonresponsive to these therapies, it is usually best to prescribe an oral antibiotic agent to get higher amounts of the drug to the infection site. You also have to be concerned that the internal hordeolum infection has spread into the pretarsal space, leading to preseptal cellulitis.

Preseptal cellulitis typically is characterized by a generalized swelling of the eyelid rather than a localized nodule. Upon palpation, preseptal cellulitis feels firm and warm with significant pain and tightness of the eyelid skin. These characteristics separate preseptal cellulitis from lid edema, which may be present with internal hordeolum.

Most infections are caused by Staphylococcus aureus or a Streptococcus species, so the oral antibiotic agent selected needs to be effective against these bacteria as well as penicillinase-producing Staphylococcus. In children, infection with Haemophilus influenzae is also a possibility.

Good choices of an oral antibiotic would include Augmentin (amoxicillin/clavulanate potassium, SK Beecham) 500 mg every 8 hours for adults or Ceclor (cefaclor, Eli Lilly) 500 mg every 8 hours for adults. Treatment with these agents should be continued for at least 10 days.

For patients who are allergic to penicillins or cephalosporins, Bactrim (Roche), 160 mg trimethoprim/800 mg sulfamethoxazole every 12 hours for adults or Levaquin (levofloxacin, Janssen-Ortho) 500 mg once daily are alternatives. Patients with sulfa allergies should avoid trimethoprim/sulfamethoxazole.

Once starting oral therapy, the patient needs to be closely monitored for improvement. While the majority of patients get better with oral antibiotics, should there be no improvement, the patient will need to be referred for intravenous antibiotic treatment.

For more information:
  • Gary E. Oliver, OD, is an associate clinical professor at the State University of New York State College of Optometry, director of optometry at Woodhull Medical Center, in Brooklyn, N.Y., and a private practitioner. He can be reached at (718) 963-8603; e-mail: geoliver.od@att.net. Dr. Oliver has no direct financial interest in the products he mentions, nor is he a paid consultant for any companies he mentions.

A. Skip topical therapy, choose orals

Elizabeth D. Muckley, OD, FAAO
Elizabeth D. Muckley

Elizabeth D. Muckley, OD, FAAO: An internal hordeolum is a bacterial infection of one of the meibomian glands in the eyelid. Patients complain of a tender or painful nodule. Staphylococcus species are usually the most common bacteria to infect the glands. In some cases, the infection can spread to the soft tissue of the eyelid and cause a preseptal cellulitis. After the infection resolves, chronic inflammation can often persist and cause a granulomatous chalazion. The primary difference between a chalazion and hordeolum is that chalazia are a result of inflammation and hordeola or styes are infectious. The symptom of pain typically points to hordeolum.

In this case, the patient has a painful hordeolum. Hot compresses and topical antibiotic/steroids (conservative therapy) were initiated, but the patient’s symptoms persisted. I am not surprised that conventional treatment did not work. Oftentimes, topical treatment does not penetrate the lid tissue effectively when it is an internal hordeolum. Due to this ineffectiveness, many clinicians are now skipping traditional, topical therapy and going right to oral antibiotics.

Because our patient was still complaining of pain with lid erythema and edema, I would recommend an oral antibiotic. Antibiotic therapy could be amoxicillin, Keflex (cephalexin, Dista), doxycycline or erythromycin. I typically use 500 mg of Augmentin (amoxicillin/clavulanate, SK Beecham) twice daily for 7 to 10 days. This has a good spectrum of coverage and is also indicated for preseptal cellulitis. In addition, the twice daily dosing is far easier for patients to comply with than an antibiotic dosed four times a day.

Steroid injection or excision while a hordeolum is “hot” or actively infected is not recommended for obvious reasons. If you can visibly see a “white head” or area of purulent material, I would recommend expression of this material in office. Expression with massage coupled with an oral antibiotic will expedite resolution, and patients show improvement within 24 hours. I counsel patients to continue hot compresses to help with the pain and tenderness. An old remedy of using a warm, hard-boiled egg or potato to apply moist heat works well for pain relief.

At the return visit, if our patient’s pain and erythema was resolved but a lump remained, then we now have a granulomatous chalazion. Chalazia respond well to steroid (Kenalog, triamcinolone acetate, Bristol-Myers Squibb) injections because the material usually consists of neutrophils, lymphocytes and plasma cells.

Kenalog injections are not without some risk. They are contraindicated for individuals with dark skin because depigmentation can occur afterwards and may be permanent. Chalazia excision and curettage is another option, especially if they are large or are present for months.

For more information:
  • Elizabeth D. Muckley, OD, FAAO, can be reached at Northeast Ohio Eye Surgeons, 2013 State Rt. 59, Kent, OH 44240; (330) 678-0201; e-mail: dredm1@aol.com. Dr. Muckley has no direct financial interest in the products she mentions, nor is she a paid consultant for any companies she mentions.

A. Early oral treatment

Tammy P. Than, MS, OD, FAAO
Tammy P. Than

Tammy P. Than, MS, OD, FAAO: I start oral treatment early on when a patient has an internal hordeolum. Because this is an infection located within the meibomian glands, it is often difficult to achieve resolution without systemic management. If an internal hordeolum fails to resolve, it may advance to preseptal cellulitis or result in a chalazion once the infection is gone. Therefore, I manage these early with oral antibiotics, often at the initial visit. Topical antibiotics have a difficult time penetrating the meibomian glands, so I will only include a topical antibiotic in the treatment regimen if there is evidence of drainage.

Assuming that the patient has no allergies or other medical history that precludes their use, I will prescribe dicloxacillin 125 mg to 250 mg four times daily for 10 days or cephalexin 250 mg four times daily for 10 days. These oral medications have been available for a long time but are still effective for soft tissue infections associated with the eye. They are inexpensive and most patients will have been exposed to them before, so tolerability should already be proven. A relatively new Keflex 750 mg can be taken twice daily, but it is not available generically and is significantly more expensive.

I will have the patient continue with warm compresses and return for follow-up in 3 to 5 days or sooner if the condition worsens. Once the pain is gone, if a mass is still present, I will have the patient begin digital massage following the warm compresses two to four times a day.

For more information:
  • Tammy P. Than, MS, OD, FAAO, is a staff optometrist at Carl Vinson VAMC/Eye Clinic. She can be reached at 458 Fairfield Dr., Dublin, GA 31021; (478) 272-1210, ext. 3341; fax: (478) 277-2706; e-mail: tammythan@bellsouth.net. Dr. Than has no direct financial interest in the products she mentions, nor is she a paid consultant for any companies she mentions.

A. Compliance low with topicals, prescribe orals

Gary E. Oliver, OD
Gary E. Oliver

Gary E. Oliver, OD: Patients with internal hordeola frequently are nonresponsive to hot compresses and topical antibiotic/steroid agents for several reasons. The patient may not be aggressive enough with the physical treatment and only use the hot compresses for a few minutes a day, therefore minimizing the benefits. A second reason is that topical drops may not sufficiently penetrate the internal hordeolum site to reach therapeutic levels.

When a patient is nonresponsive to these therapies, it is usually best to prescribe an oral antibiotic agent to get higher amounts of the drug to the infection site. You also have to be concerned that the internal hordeolum infection has spread into the pretarsal space, leading to preseptal cellulitis.

Preseptal cellulitis typically is characterized by a generalized swelling of the eyelid rather than a localized nodule. Upon palpation, preseptal cellulitis feels firm and warm with significant pain and tightness of the eyelid skin. These characteristics separate preseptal cellulitis from lid edema, which may be present with internal hordeolum.

Most infections are caused by Staphylococcus aureus or a Streptococcus species, so the oral antibiotic agent selected needs to be effective against these bacteria as well as penicillinase-producing Staphylococcus. In children, infection with Haemophilus influenzae is also a possibility.

Good choices of an oral antibiotic would include Augmentin (amoxicillin/clavulanate potassium, SK Beecham) 500 mg every 8 hours for adults or Ceclor (cefaclor, Eli Lilly) 500 mg every 8 hours for adults. Treatment with these agents should be continued for at least 10 days.

For patients who are allergic to penicillins or cephalosporins, Bactrim (Roche), 160 mg trimethoprim/800 mg sulfamethoxazole every 12 hours for adults or Levaquin (levofloxacin, Janssen-Ortho) 500 mg once daily are alternatives. Patients with sulfa allergies should avoid trimethoprim/sulfamethoxazole.

Once starting oral therapy, the patient needs to be closely monitored for improvement. While the majority of patients get better with oral antibiotics, should there be no improvement, the patient will need to be referred for intravenous antibiotic treatment.

For more information:
  • Gary E. Oliver, OD, is an associate clinical professor at the State University of New York State College of Optometry, director of optometry at Woodhull Medical Center, in Brooklyn, N.Y., and a private practitioner. He can be reached at (718) 963-8603; e-mail: geoliver.od@att.net. Dr. Oliver has no direct financial interest in the products he mentions, nor is he a paid consultant for any companies he mentions.