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Clinical Experience: Hordeolum

This week in the clinic we saw a good variety of different ailments, which was a nice change from seeing so many acute sinusitis patients recently! Although it wasn’t necessarily a challenge, one thing that was different in clinical this week was that I was the only student on a very busy day. Normally, the clinic has 3 students who assist with the patients, however on Monday I was the only student and we saw over 40 patients! Personally, I loved the fast pace and constant flow of patients. I believe this was good experience for my future as an APRN as it will allow me to be ready to see several patients, provide them patient centered care and complete all the charting.

One patient that stuck out this week was a 26 year old female who presented with a painful bump on her left upper eyelid. She stated “this bump had been there for 1 month, and is the size of a pea”. The patient reported the bump was red and painful, scoring the pain a constant 3 out of 10, and a 6 out of 10 when the bump was touched. At home the patient had attempted to treat the bump with warm compresses, and took Advil to manage the pain. Fortunately, the patient stated the bump was not affecting her vision, and according to the Snellen chart testing the patient had 20/15 vision bilaterally. When discussing the patient’s history I learned that she was diagnosed with a stye 6 months prior, and had a similar presentation, all though her stye at that time was on her bottom eyelid and protruded into her eye. She informed me that she was previously placed on erythromycin eye ointment which worked well at getting rid of her previous stye.

I performed a full physical assessment on the patient, with a focused exam on her eyes. The patient’s bump exhibited all the signs of a stye. According to Willmann et al. (2021), a stye, or a hordeolum, is a common painful, acute infectious process of the upper or lower eyelid. Generally, a hordeolum appear as a small pustule along the perimeter of the eyelid, with ninety to ninety-five percent of hordeolum occurring from Staphylococcus aureus (Willmann et al., 2021). When the localized abscess forms on the follicle of an eyelash it is considered an external hordeolum. Due to the extended duration the patient had the stye and the pain associated it was decided that the patient would need to be placed on antibiotics. Although patients with styes normally receive an ointment that can be given in the eyes, such as erythromycin, this patient had an external hordeolum which needed to be treated in a different method. After conversing with the lead ARNP of the clinic it was decided the patient would be placed on an oral antibiotic to begin treatment from the inside out. The patient was placed on PO Doxycycline 100mg to be taken twice a day for 10 days. Due to doxycycline being a bacteriostatic it works by binding to bacterial ribosomes and inhibiting protein synthesis thus being useful in treating chronic infections and inflammatory conditions that affect the eye lids (Spear & Obenchain, 2015).

Differential diagnoses for this case may include blepharitis, a chalazion, and dacryoadenitis. Blepharitis is defined as the inflammation of the base of the eyelashes or distal portion of the eyelid, and normally presents with irritated eyelid edges (Carlisle & Digiovanni, 2016). A chalazion has the most similar presentation to the hordeolum and appears as a mass within the eyelid which lasts more than 2 weeks (Carlisle & Digiovanni, 2016). The difference between these diagnoses is that a chalazion is not caused by an infection, but is a chronic condition caused by an obstruction of the Meibomian tear gland (Carlisle & Digiovanni, 2016). Finally, dacryoadenitis occurs when inflammation of the lacrimal gland is present resulting in a tender mass on the upper eyelid (Carlisle & Digiovanni, 2016).

The patient was advised to continue to perform warm compresses at home. Education on the management of styes was also reviewed with the patient and included refraining from wearing make-up, avoiding contact lenses, proper hand washing, and avoiding touching her eye unless absolutely necessary. Follow up was to be completed with the patient in forty-eight hours to monitor for improvement of the patient’s stye. The patient was also guided to call her ophthalmologist to discuss the frequency of her styes.

References

Carlisle, R. & Digiovanni, J. (2016). Differential diagnosis of the swollen red eyelid. American Family Physician, 92(2), 106-112. https://pubmed.ncbi.nlm.nih.gov/26176369/

Spear, C. & Obenchain, M. (2015). When a drop isn’t enough. Review of Optometry. https://www.reviewofoptometry.com/article/when-a-d…

Willmann, D., Guier, C., Patel, B. & Melanson, S. (2021). Stye. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK459349/#!po=…