Managing an internal hordeolum in a penicillin-allergic patient

The question:

A 30-year-old male patient presents because he woke this morning with a swollen top lid of his right eye. He had some dust fall in his right eye a few days ago while working on the garage ceiling. He rubbed his eye at the time, but it felt ok afterwards. Now the top lid is red, swollen and sore. His vision is ok and there is no discharge or photophobia. You observe an internal hordeolum nasally, and the redness and swelling extends along the whole of the top lid. He says he is allergic to penicillin as it brought him out in a rash when he was prescribed it last year. How do you proceed?

OT’s panel says...

Kevin Wallace: It is always interesting when patients present with a history of something that is probably just a red herring – but it’s important to check that there is not also a foreign body in the eye. It may be difficult to evert that lid, but I would instil fluorescein and carefully check for any signs of something there.

Most hordeoli will respond well to the usual treatment of using a warm compress. When the lid is red and angry I will usually also prescribe Chloramphenicol ointment to be applied to the lid. With experience, I have become better at deciding when topical treatment is not going to be enough. If the lid is particularly red and swollen, I would prescribe a course of antibiotic tablets. This would usually be something which is contra-indicated in a penicillin allergy so in this case the alternative on our local formulary is Clarithromycin.

This should start to resolve fairly soon, but the lump in the eyelid can take longer so the patient should continue the warm compress until it is gone. The most important advice is that, if the patient develops any symptoms which could indicate systemic infection, they need to seek help promptly.

With experience, I have become better at deciding when topical treatment is not going to be enough

Ankur Trivedi: I agree the history of the foreign body can always take you down a different route, so it is always vital to rule out multiple issues presenting concurrently.

Where there is an acute episode of hordeolum, looking at the other lids can give clues pointing towards the baseline appearance of the lid margin. It is likely there will be some underlying meibomian gland dysfunction present to some extent on the other lids also. There may also be evidence of previous acute episodes such as lid notching. This would then feed into a more general discussion around ongoing lid management even once the acute episode has settled. I find counselling the patient that such ongoing steps prevent future acute episodes can be quite motivating.

The swelling can take some time to resolve, so I make patients aware that they do need to be patient with the appropriate red flag advice, as outlined by Kevin.

Ceri Smith Jaynes: I’m trying to decide whether this is just an angry internal hordeolum or an early preseptal cellulitis. I don’t like to prescribe oral antibiotics unless they are really needed. So, my decision will depend on how it looks: how far the swelling has spread, how quickly it is progressing and any associated symptoms. I agree with Ankur and Kevin’s management plans. The College of Optometrists’ guidance for preseptal cellulitis with penicillin allergy suggests clindamycin (as an alternative to co-amoxiclav or flucloxacillin that you could have used if they were not allergic). In my local formulary, we also have doxycycline as an alternative oral antibiotic, which can be helpful for posterior blepharitis. If I am in practice for the next few days, it makes it easier to watch and wait; I can treat it topically but tell him to ring me if it’s getting worse and send me a picture.

I like people to use a Blepha EyeBag, Optase moist heat mask or similar, rather than ‘hot spoon bathing’ or using a flannel as a warm compress. This is because you can’t really control the temperature of the home remedies and I’d rather they weren’t adding a lot of heat to something already angry and inflamed. The masks deliver controlled warmth and I hope that, having invested in a product that is comforting and very easy to use, they’ll treat their meibomian glands well in the long run.

If he frequently does dusty jobs, I’d nag him about safety eyewear for the garage and recommend having eye wash or even a pack of single dose lubricants for irrigating the eye, rather than rubbing it in future.

For advice in any situation where you are unsure how to manage a patient, contact the AOP’s clinical and regulatory team via email or phone on 0207 549 2020, extension 1.