Eyelid hordeolum

What are causes of pimple on eyelid

The eyelid contains multiple glandular structures and tissue connections that protect and contribute to function of the eye. Understanding the anatomy of the orbital region guides the awareness of pathology and diagnosis of conditions presenting with a swollen red eyelid (Table 1). Issues affecting the skin elsewhere on the body, such as atopic dermatitis, insect bites, cellulitis, and necrotizing fasciitis, can occur on the skin of the eyelid. Methicillin-resistant Staphylococcus aureus (MRSA) colonization and infections can also affect the eyelid. Systemic processes, such as autoimmune disease, metastatic cancer, heart failure, and nephrotic syndrome, can manifest in the orbital region 1).

Anatomy of the Eyelid

The eyelid is a complex, fully functioning skin tissue that consists of eyelashes, lacrimal (tear) glands, sebaceous (oil or meibomian) glands, and sweat glands (glands of Zeis or Moll) 2).

Figure 1 depicts the anatomy of the orbit and eyelid. These structures can develop inflammatory reactions leading to a red, swollen eyelid. The lacrimal glands produce tears that run medially over the cornea and drain into the nasolacrimal sac 3). The eyelid and conjunctivae are colonized by the usual flora of the body, including fungi and S. aureus 4).

The orbits contain the globe, muscles for eye movement, optic nerve, arteries, veins, and surrounding fat. The orbital septum creates an anatomic barrier of connective tissue that runs from the periosteum of the skull through the eyelid. The orbital septum separates preseptal tissues from the orbital tissues.

Anatomically, the eyelid is part of the preseptal tissue. Tumor effect and inflammation posterior to the orbital septum can disrupt blood flow to the globe, impede function of the optic nerve, affect vision, and limit the function of ocular muscles 5).

The paranasal sinuses (maxillary, frontal, ethmoid, and sphenoid) abut the orbit on three sides 6). The lateral aspect of the ethmoid bone is called the lamina papyracea (Latin for “layer of paper”). It forms a thin, bony separation that can allow extravasation of inflammation from the ethmoid sinus into the orbital cavity 7).

Venous flow from the orbital region drains into the ophthalmic veins and subsequently the cavernous sinus. The teeth are in close proximity to the area, and dental pathology can present with orbital symptoms 8).

The eyelid can appear swollen because of processes in the eyelid or mass effects from the tissues posterior to the orbital septum. Prompt diagnosis is vital to guide appropriate therapy and avoid vision loss. Issues that warrant immediate ophthalmology consultation include penetrating trauma through the eyelid or into the globe, a change in vision such as diplopia, and loss of extraocular movements (ophthalmoplegia) 9).

Figure 1. Eye anatomy

eye anatomy 2

Figure 2. Eye and Eyelid anatomy

eyelid and eye anatomy

Figure 3. Eyelid anatomy

Eyelid anatomy

Figure 4. Upper Eyelid anatomy


Table 1. Conditions That Present with Eyelid Swelling

DiseaseCausesSigns and symptoms
Superficial skin processes
Atopic dermatitisSkin manifestation of systemic allergic sensitivityRaised, dry plaque
Basal cell carcinomaNeoplastic changesRaised, umbilicated lesion with overlying telangiectasia
Capillary hemangiomaLocalized growth of capillariesFlat or raised well-circumscribed erythema; increases in size with crying
Contact dermatitisLocal reaction to irritative agentIrritation, erythema, and edema
Herpes zoster ophthalmicusVaricella zoster virus infectionVesicles with surrounding erythema, possible bacterial superinfection; distributed unilaterally on forehead and upper eyelid in a dermatome
Periorbital ecchymosis (“black eye”)Blunt trauma to orbit resulting in disruption of blood vesselsEcchymosis increasing in size over 48 hours, then slowly improving
Squamous cell carcinomaNeoplastic changesPainless erythematous flaky plaques, nodules, or ulcers
Inflammatory eyelid processes
BlepharitisInflammation of the base of the eyelashes and/or distal aspects of the eyelids; inflammation of the lacrimal glandIrritated lid edges or eyelash
ChalazionNoninfectious obstruction of meibomian tear glandDiscrete mass within the lid present for two or more weeks
DacryoadenitisInflammation of the lacrimal glandCircumscribed tender mass in upper outer lid; if advanced, may appear as the diffuse inflammation of preseptal cellulitis
DacryocystitisInflammation of the lacrimal sac and ductTender mass at the medial aspect of the lower eyelid; if advanced, may appear as the diffuse inflammation of preseptal cellulitis
Hordeolum or styeHordeolum: infection of the meibomian (sebaceous) glandsPapule or furuncle at distal lid margin
Stye: infection of the sweat gland (gland of Zeis) of the eyelid
Local infections
Orbital cellulitisInfection of the soft tissues within the orbit, posterior to the orbital septum, often due to spread from local sinus diseaseRed, swollen, tender eyelid; extraocular movements limited because of pain or muscle edema; vision changes, diplopia; in children, fever and ill appearance
Preseptal cellulitisInfection of lid tissues around the orbit, often with local skin defectRed, swollen, tender eyelid; full extraocular movements; no vision changes
Mass effect from the orbit
Autoimmune orbital mass effectEdema and inflammation of ocular musclesSubacute onset bilateral proptosis, possible limited extraocular movements
Cavernous sinus thrombosisThrombosed superior ophthalmic vein and cerebral veinsHeadache, vomiting, vision changes, stupor
EndophthalmitisInflammation of the globe, often caused by penetrating traumaVision loss
Orbital neoplasmTumor effect causing proptosis and affecting ocular muscle function and nerve functionSubacute onset, unilateral, painless proptosis
[Source 10)]

Superficial Skin Processes

Herpes zoster ophthalmicus is an infection with the varicella zoster virus. It most commonly affects the frontal nerve branch of the fifth cranial nerve. Like those found elsewhere on the body, herpes zoster lesions involve the dermal tissue, leading to erythematous macules, papules, and vesicles. Lesions are typically distributed on the forehead and upper eyelid, and do not cross the midline. Hutchinson sign is the presence of vesicles on the nose, and may indicate a higher risk of ocular involvement. Cutaneous complications include ptosis, lid scarring, entropion, ectropion, depigmentation, and necrosis 11). Recognition of herpes zoster ophthalmicus and treatment with antiviral therapy is important to prevent adverse effects on the cornea and vision 12).

Basal cell carcinoma and squamous cell carcinoma account for most malignant processes of the eyelid. They are more common on the lower eyelid 13). Basal cell carcinoma accounts for 80% to 95% of eyelid and medial canthus malignancies, whereas squamous cell carcinoma accounts for 5% to 10% 14). Malignant melanoma can also involve the eyelid.13 Other less common malignancies have been reported 15).

The red tumorous growth of a capillary hemangioma can occur on the eyelid 16). In an infant, vigorous crying can make the vascular overgrowths more noticeable or larger 17).

Figure 5. Herpes simplex of the upper eyelid

Herpes simplex vesicles upper eyelid

Inflammatory Eyelid Processes

Hordeolum or stye

Hordeolum or stye is an acute, purulent inflammation of the eyelid margin usually caused by obstructed orifices of the sebaceous glands of the eyelid, usually caused by an infected eyelash root commonly caused by bacterial infection of the follicle of the eyelash 18). Stye, which affects sebaceous glands internally or externally, is common. When the meibomian gland in the tarsal plate is affected, internal hordeolum occurs. And when the glands of Zeis or Moll associated with eyelash follicles are affected, external hordeolum, or stye occurs. The onset of hordeolum is usually self limited, and may resolve in about a week with spontaneous drainage of the abscess. When the condition is severe, it can spread to adjacent glands and tissues. Recurrences are very common. As long as an internal hordeolum remains unresolved, it can develop into a chalazion or generalized eyelid cellulitis.

A internal hordeolum is an infection of the internal meibomian (sebaceous) gland, whereas a stye (external hordeolum) is an infection of the external Zeis (sweat) gland 19). These localized masses appear as papules and furuncles located distally at the lid edge 20). They typically resolve spontaneously within a few days or weeks, and warm compresses can help 21). Chronic hordeolum can lead to chalazion 22).

There are two kinds of styes:

  1. External hordeolum: A stye that begins at the base of your eyelash due to a blockage with secondary inflammation of the Zeiss or Moll sebaceous glands of the eyelid. Most are caused by an infection in the hair follicle. It might look like a pimple.
  2. Internal hordeolum: A stye inside your eyelid. Most are caused by an infection in an oil-producing internal meibomian (sebaceous) gland in your eyelid.

What is the difference between a stye and a chalazion ?

  • Sometimes it can be difficult to tell the difference between a stye and a chalazion.
  • A stye is an infection of an oil gland in the eyelid. It is like a small abscess or “boil” on the edge of the eyelid.
  • A chalazion is a small or large bump on the eye lid caused by a blocked meibomian sebaceous glands in the eyelid.

You can also get a stye if you have blepharitis. This is a condition that makes your eyelids at the base of the eyelashes red and swollen.

When you first get a stye, your eyelid is probably red and tender to the touch. Your eye may also feel sore and scratchy.

A chalazion is not usually painful. It is a bump that usually develops farther back on the eyelid than a stye. It is caused by a clogged meibomian oil gland. Rarely does it make the entire eyelid swell.

What are the treatment options for stye and chalazion ?

Here are ways to treat your stye or chalazion:

  • Warm compresses

Soak a clean washcloth in hot water and hold it to your eyelid for 10–15 minutes at a time, 3–5 times a day. Keep the cloth warm by soaking it in hot water often. For a chalazion, this warm compress helps the clogged oil gland to open and drain. You can help the gland clear itself by gently massaging around the area with your clean finger.

  • Antibiotics

Your ophthalmologist may prescribe an antibiotic for an infected stye.

  • Steroid shots

If your chalazion is very swollen, your ophthalmologist may give you a steroid shot (cortisone) to reduce the swelling.

  • Surgery to drain the area

If your stye or chalazion affects vision or does not go away, you may need to have it drained. This surgery is usually done in the doctor’s office using local anesthesia.

If a stye or chalazion keeps coming back time after time, your ophthalmologist may biopsy it. This is where a tiny piece of tissue is removed and studied. This helps your ophthalmologist check to see if there is a more serious eye problem.

  • Do not squeeze or try to pop a stye or chalazion

Doing so could spread the infection into your eyelid. Do not wear eye makeup or contact lenses while you have a stye or chalazion.

What are other treatment options for chalazion ?

Most chalazia resolve by themselves within several days to weeks, but sometimes can take months to completely disappear. Anti-inflammatory eye drops, ointments or an injection into the bump may be needed. Oral antibiotics may be used if the chalazion is associated with bacterial infection of the surrounding eyelid tissues (cellulitis). A large, swollen, or persistent chalazion might require surgical drainage. Although older children and adults can undergo the procedure in a doctor’s office under local anesthesia, general anesthesia is usually necessary to drain chalazia in young children.

Figure 6. Eyelid hordeolum (Stye)

Eyelid hordeolum


A chalazion is a noninfectious mass surrounding the meibomian gland within the midportion of the eyelid 23). Chalazia tend to present for longer than two weeks compared with the shorter natural history of sties or internal hordeola (stye) 24). Chalazia may develop from hordeola or when sebum clogs the gland 25). The skin of the eyelid appears unremarkable without findings such as a papule 26). The resultant redness of the mass effect can be confused with cellulitis; however, chalazia are not painful 27). Surgical intervention with incision and drainage can be considered for very large chalazia 28). Intralesional steroid injections have also been used for treatment if conservative management with time and warm compresses is ineffective 29).

Figure 7. A chalazion is an enlargement of an oil-producing gland in the eyelid.



Blepharitis is inflammation at the base of the eyelashes that can be chronic or acute, and is associated with dry eyes, seborrheic dermatitis, rosacea, and Demodex mite infestation. Symptoms are often worse in the morning. Treatments include warm compresses, gentle massage, washes with diluted baby shampoo, topical antibiotics, topical steroids, oral antibiotics, and combinations of these therapies 30).

Figure 8. Blepharitis



Dacryoadenitis is inflammation of the lacrimal glands, whereas dacryocystitis is inflammation of the lacrimal sac in the inferior lid 31). Both conditions can be caused by viruses or bacteria. Bacterial infections tend to be tenderer to palpation than viral infections. Staphylococcus, Streptococcus, and gram-negative organisms are common pathogens. Clinically, these processes may mimic preseptal cellulitis.

Other Eyelid skin problems

Bacterial skin infections

  • External hordeola (stye, infection of the eyelash follicle, usually caused by staphylococcus bacteria )
  • Internal hordeola (infection of the meibomian gland)
  • Bacterial conjunctivitis
  • Preseptal or orbital erysipelas or cellulitis (infections of the tissues around the eye), which is often due to spread from infection in the sinuses (responsible for 60-80% of orbital cellulitis), respiratory tract, impetigo, abscesses, trauma, or insect bites

Viral skin infections

  • Viral conjunctivitis
  • Herpes simplex (caused by the cold sore virus)
  • Herpes zoster ophthalmicus (shingles, caused by the chickenpox virus)
  • Viral warts
  • Molluscum contagiosum

Figure 9. Eyelid viral wart

Eyelid viral wart

Figure 10. Eyelid molluscum contagiosum

Eyelid molluscum contagiosum

Papules (a small pimple or swelling on the skin) and pustules (a small blister or pimple on the skin containing pus)

  • Ocular rosacea
  • Blepharitis
  • Periorificial dermatitis
  • Acne agminata

Growing solitary lesions

Skin cancers progressively enlarge.

  • Basal cell carcinoma
  • Actinic keratoses
  • Intraepidermal carcinoma
  • Squamous cell carcinoma
  • Keratoacanthoma
  • Atypical fibroxanthoma
  • Sebaceous carcinoma
  • Melanoma

Stable painless solitary lesions

  • Mole (melanocytic naevus), including congenital melanocytic naevus
  • Seborrhoeic keratosis
  • Freckles and brown marks
  • Chalazion (lipogranulomatous inflammation of the Zeis sebaceous gland at the base of the eyelash, or of the meibomian gland on the inner aspect of the lid; due to occlusion) – a firm, painless swelling
  • Salmon patch (angel’s kiss)
  • Suderiferous cyst (transparent papule containing clear fluid)
  • Other types of cyst
  • Trichoepithelioma.

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