Dacryoadenitis

Overview

Dacryoadenitis is the inflammation of the lacrimal glands. It may present acutely or chronically. It may occur unilaterally or bilaterally and there are multiple causes which can be broadly classified into:

• Infectious
• Inflammatory
• Idiopathic

It occurs commonly in children and young adults but when seen in older patients one is advised to be suspicious of malignancy or systemic autoimmune conditions.

Acute dacryoadenitis

Acute dacryoadenitis is the acute inflammation of the lacrimal gland. Commonly caused by infectious agents that affect one gland (unilateral). There are many causes of dacryoadenitis. Infection is the most common cause. Infection may arise from the conjunctiva, foreign bodies, or seeding from bacteremia.

Viral and bacterial agents are the usual culprits, rarely, fungal agents(Histoplasma, Norcadia, Blastomyces) may cause infection

Causes of dacryoadenitis

• Patient History
  • Rapid onset of symptoms
  • Pain
  • Erythema
  • Swelling
  • Excessive tearing
  • Suppurative discharge – points to a bacterial cause
  • Swollen peri-auricular and cervical lymph nodes – systemic involvement
  • Fever and malaise – systemic involvement
• Physical examination
  • Conjunctival injection
  • Cervical lymphadenopathy
  • Proptosis – Enlarged lacrimal gland is pushing the eye out
  • Eyeball movement is restricted
• Investigations Acute inflammation of the lacrimal gland does not require comprehensive evaluation as the diagnosis is clinical but you can perform the following tests:
  • Complete blood count – to ascertain whether there is an infection and differentiate whether bacterial (raised neutrophil count) or viral (raised lymphocyte count)
  • Blood cultures – to pick out the causative bacteria
  • Radiological – CT with contrast will show diffuse enlargement of the lacrimal gland (rules out tumors as no compressive changes on the orbit will be seen)
• Treatment
  • If viral, supportive treatment is advised with rest and warm compresses sufficing. NSAIDS may be given to alleviate the pain.
  • If bacterial, local antibiotics and analgesia are advised. If an abscess has formed then surgical drainage is indicated.
• Complications
  • Lacrimal abscess
  • Preseptal cellulitis
• Prognosis
  • Viral cases self-resolve in 4-6 weeks.
  • Bacterial cases require antibiotics but usually resolve with no complications.
• Differential diagnoses
  • Orbital cellulitis – associated with reduced eyeball movement
  • Eyelid abscess – fluctuant on palpation
  • Internal hordeolum – smaller circumscribed mass
  • Exophthalmos
  • Lacrimal gland tumor

There is a characteristic S-shaped swelling over the upper eyelid with proptosis

Chronic dacryoadenitis

Chronic dacryoadenitis is the chronic inflammation of the lacrimal glands. Mostly caused by inflammatory conditions.

• Etiology There are multiple causes:
  • Infectious – though uncommon, it is usually due to Mycobacterium tuberculosis and **syphilis
  • Inflammatory – Sjorgen’s syndrome, sarcoidosis, Crohn’s disease, Orbital Inflammatory Syndrome, Grave’s disease
  • Malignancy – Leukemia
  • Incompletely healed acute dacryoadenitis
  • Idiopathic inflammation
• Clinical presentation Has a less severe presentation than acute dacryoadenitisHistory
  • Gradual progression of symptoms lasting about a month
  • Painless enlargement of the lacrimal gland causing the upper eyelid to sag (mostly bilateral)
  Physical examination
  • Painless, mobile swelling over the upper eyelid
  • Ptosis (drooping upper eyelid)
  • Dry eyes – lacrimal fluid production has decreased or ceased.
  • An S-shaped curve is visible
• Investigations In cases where the presentation is chronic, atypical, or resistant to treatment the following tests can be done:
  • Anti-nuclear antibody and anti-neutrophil cytoplasmic antibody serum titers – to pick out autoimmune conditions
  • Complete blood count – rule out infection
  • Blood cultures – rule out infection
  • Smear microscopy for acid fast bacilli – to rule out M.tuberculosis
  • Radiological tests – CT with contrast
  • Tissue biopsy
  Perform other tests specific to the above causes.
• Treatment
  • Treat the underlying condition
  • The patient should be on follow-up through out the course of the disease
• Prognosis
  • Dependent on the management of the underlying condition
• Differential diagnoses
  • Periostitis of the upper orbital rim
  • Lipodermoid
  • Blepharoptosis in adults
  • Keratoconjunctivitis sicca (dry eyes syndrome)
  • Lacrimal gland tumor

REVIEW LACRIMAL GLAND ANATOMY IN THE PREVIOUS CHEAT SHEET – EMBRYOLOGY, ANATOMY AND PHYSIOLOGY OF THE EYE AND ORBIT

Resources

• Ophthalmology – A short textbook; Lang
• Medscape – https://emedicine.medscape.com/article/1210342-medication
• Youtube – https://www.youtube.com/watch?v=t3rjmkEf5xA
• National library of medicine – https://www.ncbi.nlm.nih.gov/books/NBK535384/#:~:text=Dacryoadenitis refers to inflammation of,horn of the levator aponeurosis.