Pediatric Emergency Medicine

Pearls & Pitfalls - Understanding Eyelid Infections

Larry Mellick, MD, MS, FAAP, FACEP
Professor of Emergency Medicine and Pediatrics
Medical College of Georgia

Pearl: The nomenclature and anatomy of eyelid infections can be confusing. In addition, the recommendations for eyelid infection management vary depending on the reference source used and are not well researched.

Presentation: A 7-year-old girl presented for evaluation of upper eyelid swelling. A closer examination demonstrated a small pustule on the rim of the eyelid. (See Figure 1.) An 8-year-old girl presented with lower eyelid swelling and erythema. (See Figure 2.) Both patients were treated with warm soaks with gentle massage and erythromycin ophthalmic ointment applied four times per day.

Discussion: The eyelid’s anatomy and the definitions of the associated infections are sometimes confusing to the clinician. As if that were not bad enough, the treatment recommendations concerning the use of topical antibiotics vary from source to source. No one seems to completely agree. Should one use a topical antibiotic such as erythromycin ophthalmic ointment or not?

First, let’s review the anatomy of the eyelid. (See Figure 3.) The meibomian or tarsal glands are named after a German physician, Heinrich Meibom. The glands located inside the tarsal plate and extending to the palpebral edge are long sebaceous glands that supply meibum, an oily substance with multiple roles. The primary roles of miebum is to prevent evaporation of the tear film and to make the closed lids airtight. There are approximately 50 meibomian glands in the upper eyelid and 25 in the lower eyelid. The glands of Zeis, located on the margin of the eyelid, are small sebaceous glands that produce an oily substance secreted into the center of the eyelash hair follicle. The glands of Moll are sweat glands also located near the base of the eyelashes. (See Figure 3.)

It seems that the definitions of hordeolum and chalazion overlap in various resources. Nevertheless, most sources agree on the occurrence of three different conditions: internal and external hordeola and chalazia. An external hordeolum, also known as a stye, is considered to be an infection of the sebaceous glands of Zeis or an infection of the glands of Moll, the apocrine sweat glands. An external hordeolum develops on the edge of the eyelids or palpebra and presents as a pustule or small red bump. Infections of the meibomian sebaceous glands that line the inside of the palpebrae are labeled internal hordeolums. The internal hordeola produce a swelling underneath the lid that can be seen as a visible swelling on the outside of the eyelid. Internal or external hordeola are bacterial infections caused by Staphylococcus aureus. Because they are similar to chalazia, they are often confused with those more chronic and less painful lesions. Chalazia are not infections, but are sterile lipogranulomatous reactions that present as persistent, nontender lid bulges or nodules measuring 3 to 10 mm in diameter. When a chalazion becomes large, it can cause local irritation and require surgical removal.

What about treatment of the acute infections? Most sources recommend warm soaks and gentle massage. Because there is almost no research concerning the use of topical antibiotics (or other nonsurgical treatments such as hot or warm compresses, lid scrubs, or steroids) for these conditions,1 treatment recommendations are based primarily on consensus opinions and clinical experience. Despite the lack of clinical research, the majority of clinical resources do recommend the application of topical antibiotic ointment four or five times per day.


  1. Lindsley K, Nichols JJ, Dickersin K. Interventions for acute internal hordeolum. Cochrane Database Syst Rev 2010;(9):CD007742.


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