Dacryoadenitis

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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.

Epidemiology

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.

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.

History

Acute dacryoadenitis is characterized by the following:

Chronic dacryoadenitis is characterized by the following:

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:

Systemic physical signs of acute dacryoadenitis include the following:

Chronic dacryoadenitis

Findings of chronic dacryoadenitis may include the following:

Causes

Infectious dacryoadenitis

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

Causes of bacterial dacryoadenitis include the following:

Causes of fungal dacryoadenitis (rare) include the following:

Inflammatory dacryoadenitis

Causes of inflammatory dacryoadenitis include the following:

Laboratory Studies

Acute dacryoadenitis

The following laboratory studies may be used in the workup of acute dacryoadenitis (dependent on clinical presentation):

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.

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

Medical Care

The treatment of dacryoadenitis varies with onset and etiology.

Acute dacryoadenitis

Treatment varies by etiology, as follows:

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.

Long-Term Monitoring

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.

Medication Summary

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).

Cephalexin (Keflex)

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

Cefazolin (Ancef)

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

Class Summary

Used for suspected bacterial infections.

Author

Gagan J Singh, MD, Chief of Ophthalmology, GMS Medical Eye Center, LLC; Clinical Assistant Professor, Department of Ophthalmology, West Virginia University School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Richard Ahuja, MD, Clinical Instructor, Department of Ophthalmology, University of Maryland Medical School

Disclosure: Nothing to disclose.

Specialty Editors

Simon K Law, MD, PharmD, Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Disclosure: Nothing to disclose.

Additional Contributors

Ron W Pelton, MD, PhD, Private Practice, Colorado Springs, Colorado

Disclosure: Nothing to disclose.

References

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