The role of vision therapy in the management of recurrent hordeolum

Internal hordeolum is characterized by the inflammation of the Meibomian gland due to duct blockage [1]. Recurrent styles are often associated with chronic eye rubbing or lid-fingering habits [2]. The primary causative agent of internal hordeolum is Staphylococcus aureus, with secondary infections arising from an infected chalazion. Clinical signs manifest as localized, firm, red, tender lid swelling or edema. Warm compressions aid in granuloma softening, while antibiotics can be administered locally or systemically [3]. Refractive errors, such as astigmatism, can predispose individuals to hordeolum by inducing eye discomfort, leading to eye poking. Astigmatism often presents with symptoms of asthenopia, and if uncorrected during early childhood, it may result in amblyopia [4].Although optical correction effectively addresses astigmatism, it is insufficient to manage amblyopia. Vision therapy emerges as a pivotal intervention in early childhood or school-age individuals for the effective management of meridional amblyopia [5, 6].

A 6-year-old female presented to our hospital in August 2023 with a complaint of swelling and pain in her left eyelid. She had previously experienced four episodes of pain and swelling in the previous 3 months, which resolved after using topical antibiotics (Moxifloxacin eye drops 0.5%), NSAIDs, and antibiotic eye ointment (Ocupol). However, the symptoms reappeared. Her right eye's previous prescription was 0.00–1.00 × 180, while her left eye's prescription was −2.00 × 180. However, her parents displayed a lack of adherence to the spectacles' use. Upon examination, her unaided Snellen's visual acuity for distance was 20/40 (6/12) in the right eye and 20/80 (6/24) in the left eye. Following objective refraction and cycloplegic refraction, the final refraction for the right eye was 0.00–1.50 × 180, 20/20 (6/6, N6), and for the left eye, it was 0.00–3.00 × 180, 20/80 (6/24, N18). Anterior segment examination with slit lamp examination unveiled hyperemia and diffuse edema in the upper eyelid and the presence of a swelling that was away from the lid margin and prominent on the palpebral conjunctiva. Posterior segment examination with indirect ophthalmoscope revealed normal findings. Ocular motility was full, free, and painless in all directions. Hirschberg test demonstrated a central corneal reflex. Based on the following findings a diagnosis of acute internal hordeolum with preseptal cellulitis in LE was made. Additionally, a concurrent diagnosis of simple myopic astigmatism with anisometropic amblyopia in the left eye was established.

In a meticulous non-surgical hordeolum treatment plan, topical antibiotics (Moxifloxacin eye drops 0.5%) with NSAID was given in a dose of 4 times per day which effectively tackles infection and inflammation [7]. Bedtime application of antibiotics eye ointment (Ocupol eye ointment), systemic antibiotics (Amoxicillin clavulanate tablet 375 mg) BD and oral NSAIDs (ibuprofen) syrup was given for comprehensive bacterial control and pain management respectively for 5 days. Fasting blood sugar and postprandial blood sugar tests were conducted, revealing values of 80 mg/dL and 110 mg/dL, respectively. Both readings fell within normal limits, effectively excluding metabolic disorders as a predisposing factor for hordeolum. It is noteworthy that the incidence of autoimmune-mediated type 1 diabetes in children under 15 years has been rising at a rate of 2%–5% annually [8]. Remarkably, within a week, swelling abated, and pain ceased, prompting a gradual medication tapering. Continued lid hygiene, incorporating lid scrubs and massage activities at home, ensured sustained cleanliness and preventive care. Glasses were prescribed with a final acceptance of 0.00–1.50 × 180, 20/20 (6/6, N6) for the right eye and 0.00/−3.00 × 180, 20/80 (6/24, N18) for the left eye.

Upon follow-up after 1 month, the patient presented with a less severe external hordeolum in the left eye. Two weeks later, the patient's vision with glasses was 20/20 (6/6, N6) for the right eye and 20/80 (6/24, N18) for the left eye. Refraction remained unchanged, and amblyopia therapy was continued. Subsequent examination included Keratometry and axial length biometry, revealing K1- 43.76 × 5°, K2- 45.26 × 95°; with an axial length of 23.24 mm for the right eye, and K1- 43.45 × 6°, K2- 47.17 × 96° with an axial length of 22.95 mm for the left eye. Sensory evaluation through the Worth Four Dot Test indicated left eye suppression, and stereopsis was less than 400 s of arc for distance and near using the Randot Stereo Test. Orthoptic parameters tests on the first visit showed that all the binocular parameters of the patient were affected following which she was advised for vision therapy, scheduled as 1 hour per day for 15 days. After 15 days her BCVA was (aided) 20/20 (6/6, N6) for the right eye and 20/20 (6/6, N6) for the left eye. The frequency of exercise was tapered, followed by continuous home-based dichoptic training with a bar reader and anti-suppression glasses (1 h per day). While advising tapering, we followed Mitchell's guideline to improve binocular vision parameters for accommodative-convergence disorder [9]. After 1 month, patient was re-evaluated in which all her binocular vision parameters showed significant improvement and binocularity was established. In between and during vision therapy also there was no evidence of recurrence of hordeolum. After the last session, we did the re-evaluation again for orthoptics parameters, which showed significant changes compared with the previous visit (see Table 1).

The patient came for a follow-up after 1 month of stopping therapy, and there was no deterioration of vision, along with no complaint of recurrent eyelid swelling, as shown in Figure 1. In our case, the child did not exhibit good cooperation with patching. Due to the inadequate adherence to patching therapy in children, we opted for an alternative approach by implementing active office-based therapy [10]. This approach addresses the limitations posed by poor compliance. It ensures a more dynamic and participatory method to enhance treatment effectiveness, making the therapeutic process, and potentially improving overall outcomes. The case was followed up every month for 6 months, and there were no changes in refractive error or recurrence of hordeolum. Her aided vision for the right and left eyes was 20/20 (6/6), N6, and stereopsis stayed the same 120 s of arc.

We followed the approach outlined by Hess RF et al. to address anisometropic amblyopia, the most prevalent form of amblyopia. Our strategy in the specialized amblyopia clinic involved initial monocular work, later incorporating binocular training to restore binocularity [11]. We employed various techniques like tracing, tracking training, eye-hand coordination with variable stimulus size, and contrast using the Sanet Vision Integrator (SVI) software. Additionally, Monocular Fixation on Binocular Field (MFBF) therapy with HTS iNet and Saccadic therapy were included [12]. We recommended home-based activities for 1 hour per day of red-green bar reading using red-green anaglyphic eyeglasses to facilitate dichoptic presentation. The goal was to enhance visual concentration and improve visual searching, specifically focusing on target segregation. Our guiding principle was rooted in the minimum discriminable property, aiming to enhance pursuit and saccades through tracing and tracking training. We targeted both dorsal and ventral pathways by stimulating the “what” and “where” mechanisms with variable contrast and stimulus size under Monocular Fixation on Binocular Field (MFBF) therapy. Most of our therapy focused on involving the brain in processing visual information, as shown in Figure 2.

Blurred vision in one eye can cause discomfort and lead to eye rubbing, which is a risk factor for hordeolum. Our patient had a habit of rubbing her eyes. Binocularity reduced local discomfort, resulting in the cessation of eye-rubbing activity. Recent research highlights a psychological reluctance toward undergoing patching therapy for amblyopia [10]. This case not only broadens our perspective on addressing recurrent hordeolum alongside anisometropic amblyopia but also underscores our success in managing acute hordeolum with non-surgical methods and various drugs. This case report illustrates a distinct approach to treating ocular adnexal diseases such as hordeolum, showcasing the efficacy of vision therapy in comprehensive eye care.

Shoubhik Chakraborty: Conceptualization (lead); data curation (lead); formal analysis (lead); resources (equal); supervision (equal). Pallavi Priyadarshini Sahu: Investigation (lead); resources (supporting); supervision (supporting). Soumya Kanta Mohanty: Conceptualization (equal); investigation (equal); methodology (equal); resources (equal); supervision (equal). Hajira R.: Supervision (equal); writing—review and editing (equal).

The authors declares no conflicts of interest.

The need for ethical approval was waived by the Kalinga Institute of Medical Science ethics committee for the case report.