Name of the Condition

• Commonly known as a "stye" when affecting the inner part of the eyelid, this condition is medically referred to as Hordeolum Internum. Specifically, the condition affecting the right upper eyelid is coded as H00.021.

Summary

• Hordeolum internum is an acute bacterial infection in the oil glands inside the eyelid. It typically appears as a painful, swollen bump on the eyelid, often filled with pus. It generally resolves on its own but may require medical attention if persistent.

Causes

• The primary cause of hordeolum internum is a bacterial infection, most commonly by Staphylococcus aureus. This bacteria can colonize the eyelid's oil glands, leading to inflammation and infection.

Risk Factors

• Poor eyelid hygiene
• Using expired or contaminated cosmetics
• Touching the eyes with unclean hands
• Chronic blepharitis (eyelid inflammation)
• Skin conditions such as rosacea or seborrheic dermatitis

Symptoms

• A tender, red swelling on the eyelid
• Pain or tenderness in the affected area
• Increased tear production
• Sensitivity to light
• A sensation of a foreign body in the eye

Diagnosis

• Diagnosis is typically made through a physical examination by a healthcare professional, who assesses the appearance and location of the swelling on the eyelid.

Treatment Options

• Warm compresses applied several times a day to promote drainage.
• Topical antibiotics may be prescribed if there is a secondary infection.
• Oral antibiotics in cases of severe or persistent infections.
• Incision and drainage by a healthcare professional if the hordeolum does not resolve with conservative treatment.

Prognosis and Follow-Up

• Hordeolum internum often resolves within a few days to weeks with proper management. Follow-up with an eye care provider is recommended to ensure complete resolution and to manage any complications if they occur.

Complications

• If untreated, the infection can lead to cellulitis (spreading skin infection) or chalazion (chronic, non-infectious swelling).
• Rarely, the infection can spread to involve the orbit (orbital cellulitis).

Lifestyle & Prevention

• Maintaining good eyelid and facial hygiene.
• Avoiding the use of old or shared cosmetics.
• Regularly cleaning contact lenses and makeup tools.
• Avoid touching or rubbing the eyes with unclean hands.

When to Seek Professional Help

• Significant pain or swelling that does not improve
• Vision changes or difficulties
• Spreading redness or swelling beyond the affected eyelid
• High fever or general feeling of unwellness

Additional Resources

• American Academy of Ophthalmology (aao.org)
• National Eye Institute (nei.nih.gov)
• Mayo Clinic (mayoclinic.org)

Tips for Medical Coders

• Ensure accurate laterality coding by specifying the right upper eyelid.
• Distinguish between hordeolum and other eyelid disorders such as chalazion to avoid miscoding.
• Verify any additional notes or secondary conditions that could influence coding specificity.