AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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

This condition is uncommon; therefore, data about the prevalence of this problem are sparse. One in 10,000 ophthalmic patients has this condition 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

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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
  • Pain is usually absent.
  • Enlarged gland but mobile
  • Minimal ocular signs
  • Mild ptosis may be noted secondary to enlargement of the gland
  • 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 aureus and Streptococcus
    • Neisseria gonorrhoeae
    • Treponema pallidum
    • Chlamydia trachomatis
    • Mycobacterium leprae
    • Mycobacterium tuberculosis
  • Fungal (rare)
  • • Histoplasmosis
    • Blastomycosis
    • Parasite (rare)
    • Schistosoma haematobium
    • Protozoa (rare)
    • Acanthamoeba keratitis associated
• Inflammatory
• • Sarcoidosis
  • Graves disease
  • Sjögren syndrome
  • Orbital inflammatory syndrome
  • Benign lymphoepithelial lesion

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab 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

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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).

Drug Category: Antibiotics

Used for suspected bacterial infections.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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. It is a self-limiting condition in most instances.
• Chronic dacryoadenitis: Prognosis is dependent on the management of the chronic systemic condition associated with it.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• If the conservative management of acute dacryoadenitis is not effective, then one should consider obtaining a CT scan of the orbits with contrast to rule out a malignant process. See Imaging Studies for more details.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• 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].

Article Last Updated: Jan 8, 2007