Management Practice for Hordeolum and Chalazion: A Survey of the Korean Society of Ophthalmic Plastic and Reconstructive Surgery (KSOPRS) Members

Article information

Abstract

Materials and Methods

Results

Respondents

Among 260 KSOPRS members, 80 (30.8%) completed the survey (Fig. 1). The demographic information of the 80 respondents indicated that 72 (90.0%) were oculoplastic specialists and 8 (10.0%) were general ophthalmologists. In terms of experience in ophthalmology, 15 (18.8%) had 1–5 years, 12 (15.0%) had 6–10 years, 31 (38.8%) had 11–20 years, and 22 (27.5%) had >20 years (Fig. 2A). Regarding the workplace distribution, 30 (37.5%) worked in university hospitals, 36 (45.0%) in private clinics, and 14 (17.5%) in general or eye specialty hospitals (Fig. 2B).

Fig. 1

Flowchart of the survey protocol. The survey was sent to 260 members of the Korean Society of Ophthalmic Plastic and Reconstructive Surgery (KSOPRS), with 80 participants completing the survey. The data collection process included demographic information, followed by questions on the differential diagnosis of hordeolum and chalazion, treatment approaches for each condition, postsurgical management and follow-up, and treatment in pediatric patients.

Fig. 2

Basic information of the 80 respondents. (A) Ophthalmology experience. (B) Type of institution.

Treatment of acute hordeolum

The initial treatment of acute hordeolum predominantly involves conservative approaches, with oral antibiotics, warm compresses, eyelid scrubbing, and topical antibiotic eyedrops being the most commonly used methods (Fig. 3). Warm compresses are widely recommended, with 47 respondents (58.8%) always advising their use; these are typically administered for about 8.5 days, with two or three daily applications lasting approximately 8 minutes each. This treatment is generally perceived to be effective: 54 respondents (67.6%) consider warm compresses somewhat or very effective, although 21 (26.2%) view their effectiveness as uncertain. While eyelid scrubbing is perceived as less effective than warm compresses, it is still frequently recommended, with 61 respondents (76.3%) advising its use either always (17 respondents, 21.3%) or sometimes (44 respondents, 55.0%), and only 19 respondents (23.8%) not recommending eyelid scrubbing at all. Regarding effectiveness, 39 respondents (48.8%) consider eyelid scrubbing somewhat effective, while 28 (35.0%) are uncertain about its efficacy. Forty-two respondents (52.5%) indicated that approximately half of acute hordeolum cases can improve through conservative management alone.

Fig. 3

Response among the 80 participants regarding the initial treatment of acute hordeolum without palpable lump (respondents could select multiple options).

Regarding the use of topical antibiotics, 59 respondents (73.8%) indicated that they always prescribe either antibiotic eyedrops or ointment, or both together. A significant majority (67 respondents, 83.7%) believe topical antibiotics to be effective: somewhat effective by 53 (66.2%) and very effective by 14 (17.5%). Oral antibiotics are a preferred treatment for acute hordeolum, with 47 practitioners (58.8%) reporting that they always prescribe them and 30 (37.5%) prescribing them sometimes. Cephalosporins are the most commonly prescribed class of oral antibiotics (66 respondents, 82.5%), followed by quinolones (13 respondents, 16.3%). Short-term courses lasting 4 to 5 days are typically recommended. The perceived efficacy of oral antibiotics is high, with 76 practitioners (95.0%) considering them either somewhat effective (50 respondents, 62.5%) or very effective (26 respondents, 32.5%). Steroid use is less favored, with 42 respondents (52.5%) avoiding steroids altogether, though a minority of practitioners occasionally employ topical forms (eyedrops: 24 respondents, 30.0%; ointment: 7 respondents, 8.8%).

Most respondents (77.6%) reported pursuing nonsurgical treatment for 5 to 14 days. On average, they proceed with I&C when a palpable mass persists for 12.8 days. However, 28 (35.0%) stated that they perform I&C immediately upon detecting a palpable mass. The treatment approaches differ when the hordeolum persists long enough to cause skin damage. In such cases, two-thirds of respondents reported proceeding with I&C without further delay, while one-third prefer to maintain conservative methods, including warm compresses and topical ointments.

Treatment of chalazion

Approximately half of the respondents reported initiating treatment with conservative management, including warm compresses, eyelid scrubbing, and antibiotic and/ or steroid ointments. However, the other half indicated that they employ invasive methods such as ILS injections and I&C from the outset (Fig. 4). As noninvasive treatments, 61 respondents (81.3%) reported recommending warm compresses and eyelid hygiene either always (33 respondents, 41.3%) or sometimes (28 respondents, 40.0%), while 19 respondents (18.8%) did not recommend them at all. Among those who recommended these treatments, 46 respondents (57.5%) considered them effective—34 (42.5%) found them somewhat effective and 12 (15.0%) found them very effective.

Fig. 4

Response among the 80 participants regarding the initial treatment of chalazion patients (respondents could select multiple options).

Antibiotic and steroid ointments are always recommended by 21 (26.3%), sometimes recommended by 44 (55.0%), and not recommended by 15 (18.8%). These ointments are most commonly used for 7 to 14 days (38 respondents, 47.5%), though treatment periods range from 3 days to >2 weeks. Practitioners generally perceive this treatment as less effective for chalazion than for hordeolum, with 36 (45.0%) finding the treatment somewhat effective, while 41 (51.3%) consider it barely effective or are uncertain about its efficacy.

ILS injections are recommended by 55 respondents (68.8%). Among ILS users, 30 (55.0%) prefer diluted triamcinolone acetonide (TA) and 6 (11.0%) opt for dexamethasone, with both choices aimed at minimizing side effects such as skin depigmentation. Most practitioners administer either a single injection (37 respondents, 46.6%) or two injections (34 respondents, 42.5%), with only 9 respondents (11.0%) performing up to three injections. The treatments for hordeolum and chalazion are compared in Table 1.

Table 1

Comparison of hordeolum and chalazion treatments based on the survey results (80 respondents)

Discussion

Managing hordeolum and chalazion may seem simple, but it remains a controversial issue. We therefore surveyed KSOPRS members to gather information on the current practices they use to manage hordeolum and chalazion. Initial treatments for both conditions predominantly involve conservative approaches, including warm compresses, eyelid scrubbing, and antibiotics. For acute hordeolum, the respondents commonly prescribe oral antibiotics (typically cephalosporins), along with antibiotic eyedrops and ointment. Most clinicians attempt conservative treatment for 1 to 2 weeks, and reported a 40% to 60% improvement rate. For chalazion, local steroid injections of diluted TA are considered helpful by 85% of respondents, with up to three attempts recommended. I&C is considered when lesions are large, the symptoms are severe, or conservative treatments fail. For persistent nodules after I&C, ILS injections, warm compresses, and repeat I&C are common approaches. In pediatric cases, while 50% of respondents use local anesthesia, 40% opt for general anesthesia or MAC. There is a tendency to extend nonsurgical treatments in children, reflecting a more conservative approach for pediatric patients.

While hordeolum and chalazion are sometimes used interchangeably in clinical practice, it is necessary to distinguish these two eyelid conditions to ensure that they are treated appropriately. Antibiotics are generally not indicated for chalazion, except in cases when this is infected or there is severe blepharitis or blepharitis-associated rosacea [2,11]. In contrast, antibiotics are believed to reduce the duration and severity of hordeolum, although only low-quality supporting evidence is available [2,12]. The distinction between the two conditions becomes particularly important in elderly patients, where recurrent chalazion causing changes in surrounding tissues may warrant a biopsy. Our survey found pain, redness, and swelling to be significant indicators for the differentiation, with the onset time of the lesion (acute vs. chronic) being less important. This may be due to the difficulty in determining the exact onset time of chalazion [2,13]. The primary feature distinguishing chalazion from hordeolum is the former’s lack of significant pain and suppuration.

Initial treatments for hordeolum focus on evacuating pus from the abscess, with warm compresses being widely accepted as the first-line approach [12,14]. According to our survey, 58.8% of respondents reported always using warm compresses for hordeolum, and 67.6% found them to be effective. Warm compresses are typically applied for 5 to 10 minutes two or three times daily for 7 to 10 days or until the lesion resolves. This treatment may facilitate drainage by softening the granuloma [12,15].

However, there is no evidence that warm compresses alone can eliminate the infection, since most hordeolum cases are caused by staphylococcal species. Consequently, ophthalmologists tend to prescribe combined treatments that include antibiotics [12,16]. Our survey revealed that 73.8% consistently prescribed topical antibiotics, while 58.8% routinely prescribed oral antibiotics. Although antibiotics do not significantly improve the resolution rates for chalazion or hordeolum [2,11,17], previous studies suggest that taking antibiotics improves patient satisfaction and perceived recovery [8,18]. Notably, patients treated with warm compresses alone showed reductions in lesion size similar to those taking additional antibiotics and/or steroids, highlighting the psychological impact of antibiotic prescriptions despite their low objective efficacy [2,8]. These findings underscore the complex interplay between treatment efficacy, patient expectations, and clinical practice when managing hordeolum. Additionally, while the oral antibiotics used in South Korea are predominantly cephalosporins, which are commonly used for skin and soft-tissue infections, a survey in Thailand revealed that doxycycline was the antibiotic of choice [16]. This regional difference highlights the variations in practices that may be influenced by factors such as local resistant strains.

Chalazion can primarily be managed with warm compresses and eyelid scrubbing to enhance meibomian gland function. These therapies improve drainage of the meibomian gland, and ongoing eyelid hygiene may help prevent recurrence and reduce the need for surgical intervention. Studies have found resolution rates of 25% to 50% with conservative management [5,19,20]. Relative to hordeolum, chalazion management relies less on antibiotics and more on invasive procedures [5,8]. While 73.8% of practitioners routinely prescribe topical antibiotics for hordeolum, only 26.3% do so for chalazion, with 51.3% considering them ineffective. Our survey revealed that hordeolum is typically treated nonsurgically for 5 to 14 days before invasive procedures are considered. In contrast, chalazion often progresses more rapidly to ILS injections or I&C, with nearly half of clinicians initiating invasive treatments from the outset. Wu et al. [8] suggested that physicians may consider moving directly to the use of more invasive therapies such as I&C or ILS injections for chalazion that has been present for >2 months, since longer-standing lesions are less likely to resolve with conservative therapies alone. These differences reflect the distinct pathophysiology of the conditions: hordeolum is an acute infection, whereas chalazion is a chronic, noninfectious, inflammatory lesion that often requires mechanical resolution.

ILS injections are an effective chalazion treatment option for reducing the lesion size when there is no secondary infection [7]. Our study found that 76.3% of respondents recommended ILS injections for treating chalazion. Goawalla and Lee [5] reported that their ILS group reported lower pain and inconvenience than their I&C group, indicating the former’s patient-friendly nature. ILS injections may be particularly useful for chalazion near the canaliculus to minimize the surgical risk of iatrogenic injury, multiple small chalazions, or in young children who cannot tolerate prolonged procedures [21,22]. ILS injections are also suitable for adults concerned about their appearance or requiring a rapid return to daily life. Since repeat injections are simple, they can be administered two or three times before considering I&C if there is no response [22]. The most common side effect of TA injections is localized skin depigmentation [23,24]. This risk can be avoided by diluting TA, and our study found that 66.3% of respondents prescribed either diluted TA or dexamethasone. The transconjunctival route for TA injections was also found to be safe, since it reduces the risk of localized skin depigmentation and inadvertent globe penetration [5,22]. Chalazions resolved at an average of 2.5 weeks after a single TA injection [22], and so it is advisable to wait 2 to 3 weeks before considering repeat injections.

The necessity of antibiotics following I&C for hordeolum and chalazion remains debated, and is markedly influenced by the preferences of individual practitioners. Our study found that 77.5% of KSOPRS members routinely prescribe oral antibiotics after I&C. However, their use in uncomplicated cases remains controversial. Although broad-spectrum antibiotics may be appropriate for complicated hordeolum, an infected large chalazion after I&C, or recurrent cases [2], research suggests that systemic antibiotics should be reserved for cases with significant cellulitis instead of being administered routinely [10]. While there are no reports of antibiotic-resistant bacteria following I&C with antibiotic use, practitioners should be mindful that overuse of antibiotics could lead to unintended side effects and antibiotic resistance.

Hordeolum and chalazion tend to occur more frequently in younger subjects, who may have a significant psychological aversion to invasive procedures. Consequently, there is often a preference for conservative management and delayed surgical interventions in pediatric cases. ILS injections offer a less invasive alternative but may not be well tolerated by pediatric patients, particularly when administered via the palpebral conjunctival surface [5]. Anesthesia is selected according to age, with local anesthesia preferred for older children and general anesthesia being considered more for younger patients to minimize psychiatric stress [25]. The selection of treatment method should be tailored to each child’s specific situation, taking into account factors such as age, lesion characteristics, and the ability of the child to cooperate during the procedure.

The responses to this survey indicated that IPL is a potential treatment for hordeolum and chalazion. This is consistent with previous reports that IPL therapy is beneficial for chronic hordeolum and chalazion and for preventing recurrence [25,26]. The putative therapeutic mechanism of IPL is that it shrinks small vessels around the eyelid margins, thereby reducing local inflammation and decreasing the levels of inflammatory factors. IPL also inhibits bacterial and parasite growth while providing a temporary local warming effect through selective photothermolysis. These effects combine with its ability to improve meibomian gland function, enhance the secretory ability, and reduce ocular surface inflammation [25,27].

This study had several limitations that should be considered when interpreting the results. Selection bias is an inherent limitation of survey-based research, and the restriction of the present responses to KSOPRS members potentially excludes the perspectives of primary care physicians and other specialists. The findings suggest that ophthalmologists, particularly those in subspecialty clinics such as oculoplastics, favor surgical or invasive therapy earlier in treatment or as initial management for long-standing lesions. Another limitation is that the study relied on self-reported practice preferences rather than randomized clinical trials, meaning that the results illustrate common trends rather than definitive clinical guidelines. Therefore, interpretations should be restricted to understanding more common practices, without indicating that less common behaviors are necessarily wrong.

In conclusion, this survey of the management of hordeolum and chalazion by KSOPRS members has revealed several interesting common practices that are considered valuable by current practitioners. The survey highlights a preference for conservative management as the initial treatment for both conditions, with warm compresses and eyelid scrubbing being widely recommended. For hordeolum, antibiotics are commonly prescribed despite only low-quality evidence being available for their efficacy. Chalazion management often includes ILS injections, which have high reported success rates. Further studies aimed at achieving a consensus on optimal treatment practices and the role of antibiotics will be of value to the ophthalmology community.

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