Dacryoadenitis

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.

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.

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.

Acute dacryoadenitis is characterized by the following:

• Unilateral, severe pain, redness, and pressure in the supratemporal region of the orbit

• Rapid onset (hours to days)

Chronic dacryoadenitis is characterized by the following:

• Can be bilateral, painless enlargement of the lacrimal gland present for more than a month

• More common than acute dacryoadenitis

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

Findings of chronic dacryoadenitis may include the following:

• 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

Infectious dacryoadenitis

Causes of viral dacryoadenitis (most common) include the following:

• Mumps (most common, especially in childhood)

• Epstein-Barr virus

• Herpes zoster

• Mononucleosis

• Cytomegalovirus

• Echoviruses

• Coxsackievirus A

Causes of bacterial dacryoadenitis include the following:

• Staphylococcus aureus[1] and Streptococcus

• Neisseria gonorrhoeae

• Treponema pallidum

• Chlamydia trachomatis

• Mycobacterium leprae

• Mycobacterium tuberculosis

• Borrelia burgdorferi[2]

Causes of fungal dacryoadenitis (rare) include the following:

• Histoplasmosis

• Blastomycosis

• Parasite (rare)

• Schistosoma haematobium

• Protozoa (rare)

• Acanthamoeba keratitis associated

Inflammatory dacryoadenitis

Causes of inflammatory dacryoadenitis include the following:

• Sarcoidosis

• Graves disease

• Sjögren syndrome[3]

• Orbital inflammatory syndrome

• Benign lymphoepithelial lesion

Acute dacryoadenitis

The following laboratory studies may be used in the workup of 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

Chronic dacryoadenitis is 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.

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.

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

The treatment of dacryoadenitis varies with onset and etiology.

Acute dacryoadenitis

Treatment varies by etiology, as follows:

• 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.

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

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.

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).

Class Summary

Used for suspected bacterial infections.

Cephalexin (Keflex)

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

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.