Dacryoadenitis

Background

Lacrimal system consisting of: of lacrimal gland (a), punctums (b,e), canalicules (c,f), lacrimal sac (g,d).

Lateral view of lacrimal anatamy.

• Ascension of agent from conjunctiva into lacrimal glands
• Anatomy
  • Two lobes: orbital and palpebral lobes
  • Palpebral lobe visualized by everting eyes
• Uncommon, with 1/10,000 ophthalmic patients having dacryoadenitis

Etiology

• Viral most common (mumps, EBV, HSV, CMV, echoviruses, coxsackie virus A)
• Bacterial
  • S. Aureus and strep most common
  • GC, syphilis, chlamydia, TB, mycobacterium leprae (leprosy), borrelia burgdorferi
• Fungal rare
• Inflammatory systemic (sarcoidosis, Graves' disease, Sjögren)

Clinical Features

Bilateral dacryoadenitis: erythema and edema are greatest over the lateral one-third of the upper eyelids

Chemosis and injection of the sclera

• Unilateral pain, redness, swelling, pressure in orbital supratemporal area
• Rapid onset, hours to days
• Chronic form > 1 mo
  • May be bilateral
  • May be painless
  • More common than acute form
• Physical exam
  • Chemosis, conjunctival injection, mucopurulent discharge
  • Propotosis
  • Swelling of lateral third of upper lid (S-shaped lid)
  • Systemic signs
    • Fever, URI, malaise
    • Parotid gland enlargement

Differential Diagnosis

• Lacrimal gland tumor

Periorbital swelling

Proptosis

• Normal IOP
  • Orbital cellulitis
  • Orbital pseudotumor
  • Orbital tumor
• Increased IOP
  • Retrobulbar abscess
  • Retrobulbar emphysema
  • Retrobulbar hemorrhage
  • Ocular compartment syndrome
  • Orbital tumor

No proptosis

• Periorbital cellulitis/erysipelas
• Dacryocystitis (lacrimal duct)
• Dacryocele/Dacryocystocele
• Dacryostenosis
• Dacryoadenitis (lacrimal gland)
• Allergic reaction
• Nephrotic Syndrome (pediatrics)

Lid Complications

• Blepharitis (crusts)
• Chalazion (meibomian gland)
• Stye (hordeolum) (eyelash folicle)

Other

• Subperiosteal abscess
• Orbital abscess
• Cavernous sinus thrombosis
• Conjunctivitis
• Contact dermatitis
• Herpes zoster
• Herpes simplex
• Sarcoidosis
• Granulomatosis with polyangiitis

Neonatal eye problems

• Nasolacrimal duct obstruction
• Dacrocystitis
• Conjunctivitis
  • Chemical
  • Gonococcal
  • Chlamydia
  • Herpetic
  • Streptococcus/S. Aureus
• Early onset glaucoma
• Uveitis
• Ocular foreign body
• Corneal abrasion
• Ocular trauma
• Ingrown eyelash

Evaluation

Bilateral dacryoadenitis

• CT orbits with contrast if concern for orbital cellulitis
• Bacterial culture, fungal if suspect

Management

• Warm compresses
• NSAIDs
• Based on etiology
  • Bacterial - cephalexin 500mg q6 until culture results
    • Add TMP-SMX (TMP 160mg q12hr) if concern for MRSA
  • Protozoal or fungal - treat underlying infection
  • Systemic, inflammatory/noninfectious - investigate underlying etiology

Disposition

• Outpatient ophtho referral