Current Pattern Treatment of Hordeolum by

Ophthalmologists in Thailand†
Chutima Panicharoen MD*,
Parima Hirunwiwatkul MD*
†
This paper was presented in part at the 21st Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS)
Annual Meeting, November 27-30, 2008, Bangkok, Thailand
* Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

Objective: To assess the current pattern of treatment among ophthalmologists in Thailand.

Material and Method: A two-page Thai questionnaire was distributed to Thai ophthalmologists’ annual meeting. Other
questionnaires were sent to the eye institute or conducted by telephone interviews.
Results: Five hundred one physicians participated in the present study (49.17%). Warm compression usage was suggested
(n = 459; 91.62%). The prescription before I&C was combined topical and oral antibiotics, only oral antibiotics (n = 12;
2.4%), or no oral antibiotics (n = 21; 4.19%). I&C was performed only in cases with flocculated mass in irrespective size
(n = 271; 54%), mass size of 4.47 (range 2-10 mm) (n = 124; 24.76%), or requested by patients (n = 13; 2.59%). The
prescription after I&C was combined topical and oral antibiotics, no oral antibiotics (n = 74; 14.77%), or no antibiotics at
all (n = 14; 2.79%).
Conclusion: Warm compression was commonly used. I&C was administered if there was flocculated mass. Antibiotics usage
before and after I&C was the same. First choice antibiotics were combination of neomycin, polymyxin, and gramicidine eye
drop, chloramphenicol eye ointment, and oral dicloxacillin.

Keywords: Hordeolum, Antibiotics, Hordeolum treatment, Ophthalmologist, I&C, Questionnaires

J Med Assoc Thai 2011; 94 (6): 721-4

Full text. e-Journal: http://www.mat.or.th/journal

Understanding the current treatment pattern attending the Royal College of Ophthalmologists of
of ophthalmologists will assist in the design of Thailand’s annual meeting held on July 25 to 27,
the national treatment guideline for hordeolum in 2008. This was the best strategy to obtain filled-
Thailand. Even though hordeolum is very common, to out questionnaires from as many registered
the authors’ knowledge, there is no recommended ophthalmologists or resident-in-training in a short
standard treatment guideline for this disorder. There is time. Questions consisted of physician’s general data
scarce information on the treatment for hordeolum and and hordeolum treatment. Aside from the annual
the most frustrating part is that the conclusions tend meeting, the authors also sent the questionnaires
to be vague and sometimes ungeneralizable about the to the eye institutes or conducted telephone
use of antibiotics. Therefore, the authors decided to interviews.
assess the current pattern of hordeolum treatment
among ophthalmologists in Thailand. Results
One thousand nineteen questionnaires were
Material and Method given to 863 ophthalmologists and 156 residents-in-
The authors designed a two-page Thai training. Five hundred one answered the questionnaires
questionnaire that was distributed to ophthalmologists (49.17%). There were 247 male physicians and 254 female
physicians. The mean age of the participants was
Correspondence to: 37.27 years (range 25-71). Eighty percent of them were
Hirunwiwatkul P, Department of Ophthalmology, Faculty of younger than 40 years old. There were no age data
Medicine, Chulalongkorn University, 1873 Rama IV Rd,
Pathumwan, Bangkok 10330, Thailand.
for 96 questionnaires. Most of them (80%) worked in
Phone: 0-2256-4142 ext. 205, Fax: 0-2252-8290 state-run institutions. Fifty-eight percent of them were
E-mail: parima.H@chula.ac.th general practicing ophthalmologists.

J Med Assoc Thai Vol. 94 No. 6 2011 721

 In regards to hordeolum treatment, warm Table 1. Type of first line eye drop which ophthalmologists
compression usage varied according to the use before and after I&C (n = 501)
ophthalmologists. Three hundred eighty eight (77.45%)
Eye drop Before I&C After I&C
always recommended warm compressions, 71 (14.17%) n (%) n (%)
admitted to intermittent use, and 42 (8.38%) never used
this method. The authors observed that the first line Combined antibiotics* 252 (50.30) 225 (44.91)
medications for hordeolum treatment are shown in Tobramycin 93 (18.56) 82 (16.37)
Table 1-3. Before incisional and curettage (I&C), Chloramphenicol 79 (15.77) 73 (14.57)
the combination of topical and oral antibiotics was Combined antibiotics-steroids 19 (3.79) 19 (3.79)
preferred by physicians. However, 12 (2.4%) physicians Moxifloxacin 10 (2.00) 8 (1.60)
prescribed only oral antibiotics with no topical Ciprofloxacin 6 (1.20) 6 (1.20)
Levofloxacin 1 (0.20) 1 (0.20)
medications, and 21 (4.19%) chose not to prescribe
Total antibiotics use 460 (91.82) 414 (82.63)
oral antibiotics to the patients (Table 3). None 41 (8.18) 87 (17.37)
As for I&C, 271 (54%) ophthalmologists
would use this procedure only in cases with * Combined neomycin sulfate, polymyxin B sulfate and
flocculated or pus containing mass, irrespective of gramicidin, I&C = incisional and curettage
mass size whereas others (24.76%) opted to use it when
the mass size was 4.47 (range 2-10 mm, median 5 mm).
In contrast, some will recommend I&C if the mass
duration was more than five days (range 3-30 days). Table 2. Type of first line eye gel/ointment which ophthalmo-
Only 13 out of 501 (2.59%) will send their patients to logists use before and after I&C (n = 501)
get I&C if the patients requested for the procedure.
Eye gel/ointment Before I&C After I&C
Therefore, 74 (14.77%) physicians refused to prescribe n (%) n (%)
any oral antibiotics. However, eye drops or eye
ointments were always prescribed as previously Chloramphenicol 150 (29.94) 141 (28.14)
stated. It is interesting to point out that only 14 Tetracycline 104 (20.76) 110 (21.96)
(2.79%) ophthalmologists chose not to prescribe any Fucithalmic acid 90 (17.96) 84 (16.77)
antibiotics to the patients. Tobramycin 7 (1.40) 7 (1.40)
Combined antibiotics-steroids 7 (1.40) 12 (2.40)
Discussion Total antibiotics use 358 (71.46) 354 (70.66)
None 143 (28.54) 147 (29.34)
Since the treatment for hordeolum is very
simple, hence there are several regimen variations
I&C = incisional and curettage
used by many practicing ophthalmologists. It is
generally agreed today that, based on several literature
sources, the most commonly recommended treatment
for hordeolum is warm compression several times a Table 3. Type of first line oral antibiotics which ophthalmo-
day for 10 minutes because the process is usually self- logists use before and after I&C (n = 501)
limited and will spontaneously resolve by itself after
compression within 1 to 2 weeks(1-7). Unfortunately, Oral antibiotics Before I&C After I&C
n (%) n (%)
the use of antibiotics remains controversial. For
example, Fraunfelder FT would administer topical Dicloxacillin 397 (79.24) 354 (70.66)
broad-spectrum antibiotics after I&C or in recurrent Amoxycilin 64 (12.77) 55 (10.98)
cases(8). On the other hand, some believe that systemic Bactrim 8 (1.60) 7 (1.40)
antibiotics should not be used at all unless there is Roxithromycin 4 (0.80) 4 (0.80)
significant cellutitis(1,4). Similarly, Wilkie JL stated Ciprofloxacin 3 (0.60) 2 (0.40)
that local treatment should be minimum, especially Doxycyclin 2 (0.40) 3 (0.60)
where antibiotic usage is of concern(6). Furthermore, Cefalexin 1 (0.20) 1 (0.20)
he objected to the use of I&C by declaring that it will Combined with steroids 1 (0.20) 1 (0.20)
Total antibiotics use 480 (95.81) 427 (85.23)
not allow the patient to develop his own resistance,
None 21 (4.19) 74 (14.77)
which will contribute to future recurrent hordeolum.
He stated that analgesics and warm compressions are I&C = Incisional and curettage

722 J Med Assoc Thai Vol. 94 No. 6 2011

sufficient in the treatment of hordeolum(6). Concerning mass size, and the pattern of antibiotic usage pre- and
antibiotic treatment post I&C, the authors have post-I&C were the same. The first choice antibiotics
previously shown that there may be no efficacy that Thai ophthalmologists chose to use were a
difference between the combined antibiotic combination of neomycin, polymyxin, and gramicidine
ophthalmic solution and artificial tears(3). Because of containing eye drop, chloramphenicol eye ointment, or
this, many ophthalmologists tend to use different oral dicloxacillin.
regimens based on their experiences. This was clearly
seen through the questionnaires the authors received Potential conflicts of interest
from the physicians throughout Thailand. Therefore, This study was supported by the Ratchada-
physicians may over treat the patient with the many piseksompotch Fund from the Faculty of Medicine,
options available. This will contribute to the rise of Chulalongkorn University.
drug resistant Staphylococcus aureus or inadvertent
side effects. Even though there have been no reports References
of any drug resistance pathogens, the authors need to 1. Bajart AM. Lid inflammations. In: Albert DM,
be vigilant in prescribing medications to the patients Jakobiec FA, editors. Principles and practice of
with hordeolum. Should any drug resistance pathogens ophthalmology. 2nd ed. Philadelphia: WB Saunders;
arise, it would be detrimental, especially for developing 2000: 830-1.
countries with limited resources. Aside from that, in 2. Diegel JT. Eyelid problems. Blepharitis, hordeola,
Thailand, the cost of medication is the upmost concern and chalazia. Postgrad Med 1986; 80: 271-2.
for both the physicians and patients. If there is a 3. Hirunwiwatkul P, Wachirasereechai K. Effectiveness
prevalence of drug resistant pathogens, this will of combined antibiotic ophthalmic solution in
limit accessible medicationsand will negatively affect the treatment of hordeolum after incision and
the health care system. The cost effectiveness and curettage: a randomized, placebo-controlled
efficiency of hordeolum treatment in Thailand needs to trial: a pilot study. J Med Assoc Thai 2005; 88:
be studied in the future. Therefore, in this manuscript, 647-50.
the authors report the current treatment pattern for 4. Lederman C, Miller M. Hordeola and chalazia.
hordeolum among ophthalmologists in Thailand. The Pediatr Rev 1999; 20: 283-4.
authors hope that this information will be a database of 5. Mueller JB, McStay CM. Ocular infection and
various antibiotic used for hordeolum treatment to assist inflammation. Emerg Med Clin North Am 2008; 26:
in the design and creation of the national guideline for 57-72.
the treatment of hordeolum and reduce the cost of 6. Wilkie JL. Styes. Practitioner 1956; 176: 318-21.
medications and drug resistant organisms. 7. American Academy of Ophthalmology. Hordeolum
and chalazion. In: Basic and clinical science
Conclusion course. Section 7: Orbit, eyelids, and lacrimal
In the present study, the authors assessed system. San Francisco, CA: American Academy
the pattern of treatment and discovered that warm of Ophthalmology; 2008-2009: 165-6.
compression was usually advised before any I&C 8. Fraunfelder FT. Hordeolum. In: Fraunfelder FT,
was performed, I&C was done only if there was any Roy FH, editors. Current ocular therapy. 4th ed.
flocculated or pus containing mass, irrespective of Philadelphia: Saunders; 1995: 578-9.

J Med Assoc Thai Vol. 94 No. 6 2011 723

แนวทางการรักษาภาวะต่อมไขมันใต้เปลือกตาอักเสบ (กุ้งยิง) ในปัจจุบันโดยจักษุแพทย์ใน
ประเทศไทย

ชุติมา พานิชย์เจริญ, พริมา หิรัญวิวัฒน์กลุ

วัตถุประสงค์: เพือ่ ประเมินถึงแนวทางการรักษาภาวะต่อมไขมันใต้เปลือกตาอักเสบ (กุ้งยิง) ในปัจจุบันโดยจักษุแพทย์

ในประเทศไทย
วัสดุและวิธีการ: ได้จัดทำแบบสอบถามจำนวน 2 หน้า โดยทำการสอบถามจักษุแพทย์ในงานประชุมราชวิทยาลัย
จักษุแพทย์แห่งประเทศไทย ประจำปี พ.ศ. 2551 หลังจากงานประชุมจัดส่งแบบสอบถามไปตามโรงพยาบาลต่าง ๆ
และสอบถามทางโทรศัพท์
ผลการศึกษา: ข้อมูลได้จากจักษุแพทย์ 501 ราย คิดเป็นร้อยละ 49.17 มีจกั ษุแพทย์แนะนำการประคบอุน่ กับผูป้ ว่ ย
459 ราย (ร้อยละ 91.62) ยาที่จักษุแพทย์เลือกใช้ก่อนทำการเจาะระบายหนองคือ ส่วนใหญ่ให้ยาปฏิชีวนะ
ชนิดรับประทานร่วมกับหยอดหรือป้าย มีบางส่วนให้เฉพาะยารับประทาน (ร้อยละ 2.4) และไม่ให้ยาปฏิชีวนะ
รูปแบบรับประทาน (ร้อยละ 4.19) จักษุแพทย์ 271 ราย (ร้อยละ 54) จะทำการเจาะระบายหนองกรณีท่คี ลำก้อนได้
และมีลักษณะเหมือนมีหนอง โดยไม่คำนึงถึงขนาดของก้อน ในขณะที่ร้อยละ 24.76 จะทำการเจาะระบายหนอง
กรณีที่ก้อนมีขนาดใหญ่กว่าค่าเฉลี่ย 4.47 มิลลิเมตร (2-10 มิลลิเมตร) และมี 13 ราย (ร้อยละ 2.59) ทำการเจาะ
ระบายหนอง กรณีที่ผู้ปว่ ยต้องการหลังทำการเจาะระบายหนอง ยาที่จักษุแพทย์เลือกใช้ส่วนใหญ่ยังคงให้ยาปฏิชีวนะ
รูปแบบหยอดหรือป้ายและรับประทาน มีร้อยละ14.77 ไม่ให้ยาปฏิชีวนะรูปแบบรับประทาน และมี 14 ราย (ร้อยละ
2.49) ไม่ให้ยาปฏิชวี นะ
สรุป: จักษุแพทย์ส่วนใหญ่แนะนำเรื่องการประคบอุ่น และเลือกที่จะทำการเจาะระบายหนองกรณีที่คลำก้อนได้
และมีลักษณะเหมือนมีหนองด้านใน ยาปฏิชีวนะที่จักษุแพทย์ส่วนใหญ่เลือกใช้เป็นไปในทางเดียวกันทั้งก่อนและหลัง
ทำการเจาะระบายหนอง โดยยาปฏิชีวนะที่เลือกใช้มากคือ ยาหยอดตาชนิดผสมระหว่างนีโอมัยซิน, โพลีมิกซิน และ
กรามิซิดิน ยาป้ายตาคลอแรมเฟนิคอล ยารับประทานไดคลอกซาซิลิน

724 J Med Assoc Thai Vol. 94 No. 6 2011