eMedicine Specialties > Ophthalmology > Lacrimal System

Dacryoadenitis

Gagan J Singh, MD, Chief of Ophthalmology, GMS Medical Eye Center, LLC
Richard Ahuja, MD, Clinical Instructor, Department of Ophthalmology, University of Maryland Medical School

Updated: Mar 19, 2009

Introduction

Background

The lacrimal gland is located in the supratemporal orbit. Two lobes exist, the orbital and the palpebral. The palpebral lobe is visualized easily by upper lid eversion. This eccrine secretory gland is responsible for the formation of the aqueous layer of the tear film.

By definition, dacryoadenitis is an inflammatory enlargement of the lacrimal gland. Dacryoadenitis may be separated into acute and chronic syndromes with infectious or systemic etiology.

Pathophysiology

The pathophysiology is not understood completely. Yet, infectious dacryoadenitis is thought to be caused by ascension of an inciting agent from the conjunctiva through the lacrimal ductules into the lacrimal gland.

Frequency

United States

Dacryoadenitis is uncommon; therefore, data about its prevalence are sparse. One in 10,000 ophthalmic patients has dacryoadenitis according to one report. Inflammatory enlargement of the lacrimal gland is much more common than lacrimal gland tumors.

Mortality/Morbidity

No data are available. Acute dacryoadenitis tends to be a self-limiting condition. Patients with chronic dacryoadenitis need management of their systemic condition.

Race

No racial predilection is noted.

Sex

No sexual predilection is noted.

Age

No age predilection is noted.

Clinical

History

Acute dacryoadenitis
- Unilateral, severe pain, redness, and pressure in the supratemporal region of the orbit
- Rapid onset (hours to days)
Chronic dacryoadenitis
- Can be bilateral, painless enlargement of the lacrimal gland present for more than a month
- More common than acute dacryoadenitis

Physical

Acute dacryoadenitis
- The palpebral lobe of the lacrimal gland is often involved and is easily seen by everting the upper lid. It is noted to be prolapsed and enlarged. The palpebral lobe tends to be firm and tender upon palpation through the lid.
- Other associated ophthalmic physical signs of acute dacryoadenitis include the following:
  - Chemosis (conjunctival swelling)
  - Conjunctival injection
  - Mucopurulent discharge
  - Erythema of eyelids
  - Lymphadenopathy (submandibular)
  - Swelling of the lateral third of the upper lid (S-shaped lid)
  - Proptosis
  - Ocular motility restriction
  - Globe displacement inferiorly and medially
  - Increased severity of signs and symptoms with orbital lobe involvement
  - Acanthamoeba keratitis associated (rarely)
- Systemic physical signs of acute dacryoadenitis include the following:
  - Parotid gland enlargement
  - Fever
  - Upper respiratory infection
  - Malaise
Chronic dacryoadenitis
- Less severe presentation than acute dacryoadenitis
- No pain (usually)
- Enlarged gland but mobile
- Minimal ocular signs
- Mild ptosis secondary to enlargement of the gland (possible)
- Mild-to-severe dry eyes

Causes

Infectious
- Viral (most common)
  - Mumps (most common, especially in childhood)
  - Epstein-Barr virus
  - Herpes zoster
  - Mononucleosis
  - Cytomegalovirus
  - Echoviruses
  - Coxsackievirus A
- Bacterial
  - Staphylococcus aureus¹ and Streptococcus
  - Neisseria gonorrhoeae
  - Treponema pallidum
  - Chlamydia trachomatis
  - Mycobacterium leprae
  - Mycobacterium tuberculosis
  - Borrelia burgdorferi²
- Fungal (rare)
  - Histoplasmosis
  - Blastomycosis
  - Parasite (rare)
  - Schistosoma haematobium
  - Protozoa (rare)
  - Acanthamoeba keratitis associated
Inflammatory
- Sarcoidosis
- Graves disease
- Sjögren syndrome³
- Orbital inflammatory syndrome
- Benign lymphoepithelial lesion

Differential Diagnoses

Cellulitis, Orbital	Exophthalmos
Cellulitis, Preseptal	Hordeolum
Chalazion	Lacrimal Gland Tumors
Dermoid, Orbital	Ptosis, Adult
Dry Eye Syndrome

Workup

Laboratory Studies

Acute dacryoadenitis (dependent on clinical presentation)
- Smear and culture if purulent discharge is noted.
- Blood cultures to rule out N gonorrhoeae infections
- Immunoglobulin titers to specific virus; not usually indicated (see Causes)
Chronic dacryoadenitis
- Usually seen with chronic systemic conditions (eg, sarcoidosis, Sjögren syndrome, Graves disease). Seek advice from the patient's internist. Lacrimal gland biopsy may provide helpful information.
- Rule out infectious causes (rare). They include syphilis, leprosy, tuberculosis, and trachoma.

Imaging Studies

Acute dacryoadenitis
- CT scan of the orbits with contrast can be helpful. The affected lacrimal gland shows diffuse enlargement, oblong shape, and marked enhancement with contrast.
- No compressive changes in the contiguous bone or globe are noted.
Chronic dacryoadenitis
- CT scan of the orbits with contrast show similar findings when compared to acute dacryoadenitis, except that chronic lesions show no marked enhancement with contrast. In addition, the lacrimal gland changes may be bilateral in contrast to acute dacryoadenitis.
- Again, no compressive changes in the contiguous bone or globe are noted. If these changes are noted, then consider lacrimal gland tumors.

Histologic Findings

Lacrimal gland biopsy results vary depending upon the etiology. Biopsy is not indicated in acute dacryoadenitis.

Sarcoidosis - Noncaseating granulomatous tubercles, lymphocytic infiltration, and replacement of secretory acini by fibrous tissue

Graves disease - Lymphocytic infiltrate with edematous fibrous tissue and glandular degeneration

Sjögren syndrome - Lymphocytes and plasma cells infiltration

Treatment

Medical Care

The treatment of dacryoadenitis varies with onset and etiology.

Acute dacryoadenitis
- Viral (most common) - Self-limiting, supportive measures (eg, warm compresses, oral nonsteroidal anti-inflammatories)
- Bacterial - Initiate with first-generation cephalosporins (eg, Keflex 500 mg qid) until culture results are obtained.
- Protozoan or fungal related - Treat the underlying infection accordingly with specific antiamoebic or antifungal agents.
- Inflammatory (noninfectious) - Investigate for systemic etiology, and treat accordingly.
Chronic dacryoadenitis
- In most cases, treat the underlying systemic condition.
- If the enlargement does not subside after 2 weeks, consider lacrimal gland biopsy.

Consultations

When considering sarcoidosis, tuberculosis (TB), Sjögren syndrome, or Graves disease as the etiology, consultation with an internist is important.

Medication

Gram-positive organisms are the most common cause of acute bacterial dacryoadenitis. Therefore, initiating coverage for these organisms is important prior to obtaining culture results. Cephalexin (Keflex) is an excellent choice. If the patient needs to be hospitalized because of the severity of illness, then use IV cefazolin (Ancef).

Antibiotics

Used for suspected bacterial infections.

Cephalexin (Keflex)

Provides excellent broad-spectrum coverage for both gram-positive and gram-negative organisms associated with dacryoadenitis.

Dosing

Adult

1-4 g/d PO in divided doses

Pediatric

Not established
Recommended dose: 25-50 mg/kg/d PO divided qid

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Follow carefully for allergic reaction

Cefazolin (Ancef)

First choice in IV medication for dacryoadenitis. Provides excellent broad-spectrum coverage for both gram-positive and gram-negative organisms associated with dacryoadenitis.

Dosing

Adult

1 g IV q8h

Pediatric

<1 month: Not established
>1 month: 50-100 mg/kg/d IV divided tid

Interactions

Probenecid may decrease renal tubular secretion of cefazolin when used concurrently, resulting in increased and more prolonged cefazolin blood level

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Monitor for allergic reaction

Follow-up

Further Outpatient Care

Acute dacryoadenitis: For most patients, 2-6 weeks of follow-up care on an outpatient basis is necessary after beginning the initial treatment.
Chronic dacryoadenitis: Patient should receive follow-up care, in conjunction with the primary care physician, on an outpatient basis.

Prognosis

Acute dacryoadenitis: Prognosis is good. Acute dacryoadenitis is a self-limiting condition in most instances.
Chronic dacryoadenitis: Prognosis is dependent on the management of the associated chronic systemic condition.

Miscellaneous

Medicolegal Pitfalls

If the conservative management of acute dacryoadenitis is not effective, then one should consider obtaining a CT scan of the orbits with contrast (see Imaging Studies) to rule out a malignant process.

References

Kubal A, Garibaldi DC. Dacryoadenitis caused by methicillin-resistant Staphylococcus aureus. Ophthal Plast Reconstr Surg. Jan-Feb 2008;24(1):50-1. [Medline].
Nieto JC, Kim N, Lucarelli MJ. Dacryoadenitis and orbital myositis associated with lyme disease. Arch Ophthalmol. Aug 2008;126(8):1165-6. [Medline].
Kamao T, Miyazaki T, Soga Y, et al. Genetic dissociation of dacryoadenitis and sialadenitis in a Sjogren's syndrome mouse model with common and different susceptibility gene loci. Invest Ophthalmol Vis Sci. Feb 14 2009;[Medline].
Boruchoff SA, Boruchoff SE. Infections of the lacrimal system. Infect Dis Clin North Am. Dec 1992;6(4):925-32. [Medline].
Brindley GO. Dacryoadenitis. In: Oculoplastic and Orbital Emergencies. Appleton & Lange: 1990:45-50.
Fitzsimmons TD, Wilson SE, Kennedy RH. Infectious dacryoadenitis. In: Ocular Infection and Immunity. St Louis, Mo: Mosby; 1996:1341-45.
Jakobiec FA, Yeo JH, Trokel SL, et al. Combined clinical and computed tomographic diagnosis of primary lacrimal fossa lesions. Am J Ophthalmol. Dec 1982;94(6):785-807. [Medline].
Massaro BM, Tabbara KF. Infections of lacrimal apparatus. In: Infections of the Eye. Boston: Little Brown; 1996:551-8.
Podos SM, Yanoff M. Acute dacryoadenitis. In: Textbook of Ophthalmology - External Disease. Europe: Mosby-Year Book; 1994:1414-6.
Rhem MN, Wilhelmus KR, Jones DB. Epstein-Barr virus dacryoadenitis. Am J Ophthalmol. Mar 2000;129(3):372-5. [Medline].
Tomita M, Shimmura S, Tsubota K, Shimazaki J. Dacryoadenitis associated with Acanthamoeba keratitis. Arch Ophthalmol. Sep 2006;124(9):1239-42. [Medline].

Keywords

dacryoadenitis, acute dacryoadenitis, chronic dacryoadenitis, lacrimal gland, lacrimal gland inflammation, inflammation of lacrimal gland, inflammatory enlargement of lacrimal gland, lacrimal gland tumors

Contributor Information and Disclosures

Author

Gagan J Singh, MD, Chief of Ophthalmology, GMS Medical Eye Center, LLC
Gagan J Singh, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, and American Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Richard Ahuja, MD, Clinical Instructor, Department of Ophthalmology, University of Maryland Medical School
Richard Ahuja, MD is a member of the following medical societies: American Academy of Ophthalmology and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Ron W Pelton, MD, PhD, Private Practice, Colorado Springs, Colorado
Ron W Pelton, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Colorado Medical Society, Utah Medical Association, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic
Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience
Disclosure: Allergan - Botox Cosmetic Consulting fee Consulting; Quest medical - lacrimal balloons Honoraria Speaking and teaching; Ortho-Neutrogenia Consulting fee Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

Further Reading