Moran CORE

Open source ophthalmology education for students, residents, fellows, healthcare workers, and clinicians. Produced by the Moran Eye Center in partnership with the Eccles Library

Search Moran CORE

What is a stye and how do you treat it?

Contributors: BCK Patel MD, FRCS, Jay Patel BSC, Raman Malhotra FRCS
Photographer:  BCK Patel MD, FRCS
Posted January 12, 2021

Definition of a Stye: A stye is caused by a bacterial infection of the gland of Zeis that opens into the follicle of an eyelash. The appearance is one of a red or red-yellow lesion along the eyelid margin, usually associated with an eyelash. The area will be swollen, painful and tender to the touch.  Staph aureus is the causative organism in 90% of styes.

Fig 1. Cross-section depiction of the eyelid margin showing the relationship of the Meibomian gland, the eyelashes and the glands of Zeis and Moll

Fig 1. Cross-section depiction of the eyelid margin showing the relationship of the
Meibomian gland, the eyelashes and the glands of Zeis and Moll

 

Fig 2. A stye or external hordeolum is an infection of the gland of Zeis which opens into the eyelash follicle. There will be erythema around the eyelash follicle with local tenderness

Fig 2. A stye or external hordeolum is an infection of the gland of Zeis which opens into the eyelash follicle. There will be erythema around the eyelash follicle with local tenderness

Synonyms: External hordeolum, Zeisian sty, In the Black Country in Britain, styes were called “powks”.

Etymology: Stye: derived from Old English from the 15th century word stigend (meaning a small tumor on the edge of the eyelid) derived from stigan (to climb, ascend or rise) and Middle English “eie” (meaning eye). So, stigan + eie = sty + eye = stye! Stye was first recorded in the 17th Century.

Etymology of “Hordeolum”: derived from hordeum, which is Latin for “barley”. The diminutive of hordeum is hordeolus.  “-olus” refers to the resemblance to a barley grain in shape, size and color. Hence the term “Hordeolum”. The appearance of a stye on the eyelid margin is that of a small grain of barley:

Fig 3. Grains of barley

Fig 3. Grains of barley

When a chalazion points forwards or backwards through the tarsal conjunctiva, the yellowish appearance resembles a grain of barley, hence the term “external hordeolum” often used for a chalazion presenting with eruption through the skin and “internal hordeolum” for the inner eyelid white spot seen with posterior eruption.

Glands of Zeis: glands of Zeis are sebaceous glands which open via an excretory duct into the middle of the hair follicle. There are one to two glands of Zeis per eyelash. Glands of Zeis are also holocrine sebaceous oil glands that open into the middle portion of the hair follicle. There are one to two glands of Zeis per eyelash. The sebum they produce serves to stop the eyelashes from becoming brittle. A mildly moist sheen is formed on healthy eyelashes. There are up to 150 eyelashes on the upper eyelid and up to 80 eyelashes on the lower eyelid. They generally grow in two layers, with the posterior layer being finer. One to five lashes are lost in a 24 hour period as lashes go through growth cycles.

Etymology of glands of Zeis: named after Eduard Zeis (1807 – 1868), a German ophthalmologist and plastic surgeon. In 1838, he published the first textbook dedicated to plastic surgery, “Handbuch der plastischen Chirurgie” and is recognized as having established the term plastic surgery (plastische chirurgie). Zeis also published a monogram, Die Literatur und Geschichte, which contained practically every reference to plastic surgery before 1864. In spite of these notable achievements, his name is little known today in the Plastic Surgery world, and only by ophthalmologists because of the gland of Zeis. The great Dieffenbach wrote the foreward to Zeis’s Handbuch, in which he described plastic surgery as the “finest flower of all surgery.”It was Friedrich August von Ammon who took Zeis under his wing when Zeis returned to Dresden to practice medicine and encouraged the young Zeis to study “the glandular structures of the eyelids”. Zies was the first to distinguish between the Meibomian glands and the sebaceous glands associated with hair follicles, now called Zeis glands.

Fig 4. The frontispiece of the Handbuch der Plastischen Chirurgie

Fig 4. The frontispiece of the Handbuch der Plastischen Chirurgie

When Zeis was appointed to the University of Marburg to become its Professor of Surgery, von Ammon wrote this about him: “In character he is friendly, not quarrelsome, without pedantry, upright, honourable, mature, sociable, high principled without being ambitious, free from any traits of gossiping or scandal mongering”. A reference such as this would be one the modern surgeon would do well to aspire to!

Zeis, as professor of surgery, expected his students to have command of at least six languages, including Latin and Greek, besides command of the medical subjects.

Facts of historical interest in the management of styes: In Britain, an old wive’s tale was to rub a gold wedding ring on a stye daily. It is thought that the pressure of this action would have helped resolve the stye. Another treatment that was popular in Britain was the use of tealeaf poltice which was applied through the night on a child’s eyelids. Poultices were also made with stale bread and hot water. Another old saw was that mum had to put the golden wedding ring in her mouth before rubbing it on the stye. Boracic acid solution was also used to soak eyelids that had styes. In certain parts of Africa, pigeon droppings are applied to a stye.

Natural history and management of Styes: A stye will present as a small, tender, red or yellow bump at the root of an eyelash. Although there will be some swelling around the root of the eyelash, the rest of the eyelid is not affected. They usually occur as solitary lesions and, contrary to chalazia, are rarely bilateral.

Most styes will “pop” within a few days and will resolve without treatment. If a stye is persistent, the medical textbooks recommend epilation of the eyelash where the gland of Zeis is inflamed. We tend to treat styes with a topical antibiotic or antibiotic and steroid ointment three times a day for a week. If it still persists, we have found that simply releasing the collection in the gland of Zeis with local anesthetic and preserving the eyelash works perfectly well. As a patient once said to me, “there is only one thing more important to a woman than her husband, her eyelashes”.

Fig 5. A stye or external with erythema and a “barley-like” lesion around the root of an eyelash

Fig 5. A stye or external with erythema and a “barley-like” lesion around the root of an eyelash

 

Fig 6. A typical stye with infection at the root of a lash

Fig 6. A typical stye with infection at the root of a lash

References

  1. WillmannD, Guier CP, Patel BCK,, Melanson SW. Stye. StatPearls, Treasure Island (FL): StatPearls Publishing. Aug 2021. https://pubmed.ncbi.nlm.nih.gov/29083787/ PMID:29083787
  2. Patel BCK, Joos ZP. Diseases of the eyelashes. StatPearls, Treasure Island (FL): StatPearls Publishing. Aug 2021. https://pubmed.ncbi.nlm.nih.gov/30725785/ PMID:30725785