A 28-year-old woman presents with a painful, red swelling on the upper eyelid margin that started 3 days ago. She reports localized tenderness and mild purulent discharge from the lesion. On examination, there is a small pustule at the lid margin with surrounding erythema and edema. The lesion is tender to touch. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: External Hordeolum (Stye) ### Key Clinical Features **Key Point:** An external hordeolum is an acute, purulent inflammation of the glands of Zeis or Moll at the eyelid margin, presenting with rapid onset, pain, and visible pustule formation. The patient's presentation is classic for external hordeolum: - **Acute onset** (3 days) - **Pustule at lid margin** with purulent discharge - **Pain and tenderness** (distinguishes from chalazion) - **Localized erythema and edema** ### Differential Features | Feature | External Hordeolum | Internal Hordeolum | Chalazion | |---------|-------------------|-------------------|----------| | **Location** | Lid margin (at lash line) | Lid margin (conjunctival side) | Lid margin or deeper | | **Onset** | Acute (2–3 days) | Acute (2–3 days) | Insidious (weeks) | | **Pain** | Marked, tender | Marked, tender | Painless (unless infected) | | **Pustule** | Visible externally | Not visible externally | Absent | | **Discharge** | Purulent, external | Purulent, internal | Lipid-rich, granulomatous | | **Gland involved** | Glands of Zeis/Moll | Meibomian gland | Meibomian gland | **Clinical Pearl:** The presence of a **visible pustule at the lid margin** with purulent drainage is pathognomonic for external hordeolum. Internal hordeolum may show a pustule on the conjunctival surface but NOT at the lash line. ### Pathophysiology 1. Bacterial infection (commonly *Staphylococcus aureus*) of sebaceous glands at lid margin 2. Acute suppurative inflammation → localized abscess formation 3. Pustule ruptures, draining pus externally **High-Yield:** External hordeolum = **acute, painful, pustule at lid margin**; Chalazion = **chronic, painless, lipogranulomatous nodule**. ### Management - Warm compresses (15 min, 4–6 times daily) to promote drainage - Topical antibiotics (erythromycin or bacitracin ointment) if secondary infection risk - Oral antibiotics if cellulitis or recurrent (consider *S. aureus* coverage) - Incision and drainage if pointing and not self-draining - Lid hygiene and avoid eye makeup during acute phase **Tip:** Most external hordeola resolve spontaneously within 1–2 weeks with conservative management.