Dacryoadenitis - Causes, Symptoms, Treatment and Complications

Introduction

Dacryoadinitis is an inflammatory condition of the lacrimal glands or tear glands of the eyes. The infection of the lacrimal glands is more common in young adults and children. It can present both unilaterally and bilaterally. Dacryoadenitis is caused due to many factors and can be either acute or chronic.

The lacrimal gland is present in the lateral aspect of the orbit. Its secretions, also known as tears, are used to cleanse the dirt from the eyes and lubricate them. The lacrimal gland comprises different parts, such as the palpebral and orbital lobes, separated by the lateral horn of the levator aponeurosis.

What Causes Dacryoadenitis of the Eyes?

Dacryoadenitis is multifactorial; it can be either inflammatory, idiopathic (unknown cause) or infectious. The various factors responsible for inflammation of the lacrimal gland are -

• Viral infections like Epstein-Barr, herpes, mumps, etc., may cause dacryoadenitis.

• Bacteria like Staphylococcus aureus cause bacterial infections, and Streptococcus pneumoniae may cause the condition. The bacterial infections are primarily spread from the conjunctiva, skin, and penetrating trauma.

• Fungal infections can be caused by fungi such as Histoplasma, Blastomyces, and Nocardia.

• Inflammatory conditions responsible for dacryoadenitis are Sjogren's syndrome (an autoimmune disorder characterized by dry mouth and dry eyes), Crohn's disease (inflammatory bowel disease), and granulomatosis with polyangiitis.

• Immunoglobulin G4 (IgG4) related dacryoadenitis is a type of idiopathic dacryoadenitis.

• Autoimmune disorders.

Dacryoadenitis is more common in patients with

• Autoimmune disorders like Sjogren's syndrome.

• Ig 4-related disorders.

What Are the Various Types of Dacryoadenitis?

Dacryoadinitis can be divided into two types based on the onset of the infection.

• Acute: Infectious causes and typically unilateral presentation cause acute dacryoadenitis.

• Chronic: Inflammatory causes mainly cause chronic dacryoadenitis.

How Common Is Inflammation of the Lacrimal Gland?

The exact prevalence of the inflammation of the lacrimal gland is not known. However, the estimated number of cases of dacryoadenitis is far less than dacryocystitis (inflammation of the lacrimal sac). An acute form of infection is more common in young adults and children. The autoimmune form of the disorder is more prevalent in females than males.

What Are the Clinical Presentations of Dacryoadenitis?

The clinical features of the condition are -

• Erythema of the upper part of the orbit.

• Enlargement of the lacrimal gland.

• Drooping the lateral portion of the eyelid gives it an S-shaped curve.

• Swollen periauricular and cervical lymph nodes.

• Purulent discharge from the lacrimal glands.

• Fever.

• The inflammatory form of the disease shows a bilateral presentation compared to the infectious form, which is most acute and affects only one eye.

• Patients with chronic dacryoadenitis are asymptomatic.

• In the rarest of cases, the infection can impair vision.

It is necessary to seek professional help if the swelling and pain persist even after treatment.

How Are Patients With Dacryoadenitis Evaluated?

The acute form of the condition is associated with bacterial, viral, or fungal infections and can be quickly evaluated based on the patient's clinical signs and medical history.

• In atypical cases, comprehensive laboratory investigation is beneficial. The numerous lab investigations performed to determine the etiology of the condition are:

  • Complete blood count (CBC).

  • Anti-nuclear antibody (ANA).

  • Anti-neutrophil cytoplasmic antibody (ANCA).

  • Erythrocyte sedimentation rate (ESR).

A thyroid function test can be performed to rule out thyroid disease.

• Imaging techniques like computed tomography (CT scan) and magnetic resonance imaging (MRI) are performed in cases with oblong and enlarged lacrimal glands.

• The acute form of the state shows scleral enhancement (scleritis and episcleritis), which is absent in the chronic form of the condition.

• Culturing of the purulent discharge is imperative in bacterial conditions.

• A lacrimal gland biopsy is done in atypical cases with unknown etiologies. The biopsy is performed via a transcutaneous approach to prevent the tearing of the duct.

How Is Dacryoadenitis Managed?

Viral dacryoadenitis does not require systemic antivirals and resolves within four to six weeks. At the same time, bacterial infections may require systemic medications and surgical drainage in case of an abscess.

• Corticosteroids are given to reduce inflammation.

• Surgical debulking is performed in idiopathic cases, which lowers the relapse rate.

• Refractory cases are managed with radiotherapy and drugs like Methotrexate, Rituximab, etc.

• A lacrimal biopsy is essential in non-responsive cases.

What Are the Conditions That Mimic Dacryoadenitis?

The disease that shares similarities with dacryoadenitis is -

• Malignancy, especially in older individuals with the presentation of a non-healing swelling.

• Lymphomatous lesions.

• Epithelial tumors of the gland like mixed malignant carcinoma, mucoepidermoid carcinoma, etc.

• Thyroid eye disease shows diplopia similar to dacryoadenitis.

• Infectious conditions like orbital cellulitis.

How Can the Patients Be Educated About the Condition?

Patients suffering from dacryoadenitis must be made aware of the disease, its nature, and the management of the condition.

• The self-resolving tendency of the disease should be explained to the patient.

• Regular monitoring of the patient for eye movement and pain is necessary to prevent further complications.

• Dacryoadenitis associated with mumps can be prevented by vaccinating children for mumps.

• The patient should be educated about long-term immunomodulatory medications in case of autoimmune-mediated dacryoadenitis.

Regular follow-up of the disease is essential to -

• Prevent the loss of visual acuity.

• Reduce eye movement pain.

• Detect pupillary defects and abnormal color vision.

Overall the condition resolves without any complications with or without medications. However, inflammatory cases require more attention and additional management strategies.

What Are Complications That Are Linked to Dacryoadenitis?

The state or condition, in rare cases, may lead the severe infectious complications of the eyes, such as -

• Pre-septal cellulitis.

• Orbital cellulitis.

• Abscess formation.

• Decrease in tear production.

Conclusion

Dacryoadenitis is an inflammatory condition of the lacrimal glands that can originate from infection or inflammation. Based on the onset duration, it occurs either in acute form or chronic form. Patients with the chronic form of dacryoadenitis remain asymptomatic. Acute forms of the disease can be easily diagnosed based on clinical features and confirmatory laboratory tests. Dacryoadenitis, in most cases, resolves by itself, and corticosteroids can be used to reduce inflammation. Surgery of the lesion is recommended in severe cases. Regular follow-up is necessary to prevent further complications. The condition usually have a good prognosis.