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Diseases of the lacrimal apparatus

Last updated: December 3, 2019

Summary

The lacrimal apparatus consists of the lacrimal gland, which secretes the aqueous layer of the tear film, the lacrimal sac, into which the tears drain, and the nasolacrimal duct, through which the tears drain into the nose. Inflammation of the lacrimal gland is called dacryoadenitis and is commonly caused by viral or bacterial infections. The condition typically presents with conjunctival hyperemia, S-shaped ptosis, mucopurulent discharge, and discomfort. Dacryostenosis refers to the congenital or acquired obstruction of the nasolacrimal duct (NLD) and presents with excessive tearing. NLD obstruction can cause stasis of tears in the lacrimal sac, which predisposes to secondary bacterial infection of the sac, known as dacryocystitis. The diagnosis is usually clinical, and may be supported by bacterial cultures, imaging (CT, x-ray), and probing of the nasolacrimal duct. Treatment is often conservative (e.g., NSAIDs, warm compresses), but may also require antibiotics in cases of bacterial infections or invasive procedures to remove obstructions (e.g., NLD dilation).

Dacryoadenitis

	Acute dacryoadenitis
Definition	Acute inflammation of the lacrimal gland
Etiology	Infection (most common) Viral: mumps, EBV, CMV, herpes zoster Bacterial: S. aureus, Streptococcus, Gonococcus, Mycobacterium tuberculosis Fungal: histoplasmosis, blastomycosis Inflammatory
Clinical features	Rapid onset and progression Unilateral pain/discomfort over the lacrimal gland (lateral upper eyelid) Characteristic S-shaped ptosis , possibly proptosis Palpebral conjunctival hyperemia and chemosis; possibly mucopurulent discharge Limitation of eye movement, diplopia (indicates orbital cellulitis) Ipsilateral preauricular lymph node enlargement and fever may be present.
Diagnostics	Eye swabs: in patients with ocular discharge Complete blood count, blood culture, viral serologies: in patients with fever CT scan: to look for evidence of orbital cellulitis
Treatment	Viral dacryoadenitis may be self-limiting. Broad-spectrum IV antibiotics: in febrile patients, presence of purulent discharge, positive blood/eye swab cultures

References:^[1]^[2]^[3]^[4]^[5]^[6]

Acute dacryoadenitis

Dacryostenosis

Congenital dacryostenosis

Definition: nasolacrimal duct (NLD) atresia/obstruction in an infant caused by a developmental anomaly and characterized by epiphora (excessive tearing)
Incidence: up to 6% of live births (common condition)
Clinical features
- Epiphora within 2–4 weeks of birth
- Palpation of the lacrimal sac may cause tears to leak from the lacrimal punctum.
Diagnostics: clinical diagnosis; syringing or probing of the duct to determine the site of obstruction and remove the obstruction, if necessary
Treatment: lacrimal sac massage; dilation or stenting of the duct; dacryocystorhinostomy if other measures fail
Complications (of untreated dacryostenosis): acute/chronic dacryocystitis

Congenital dacryostenosis (valve of Hasner) Lacrimal sac massage (Crigler massage)

Acquired dacryostenosis

Etiology
- Concretions in the NLD
- Granulomatous diseases: sarcoidosis; granulomatosis with polyangiitis, tuberculosis
- Punctal stenosis: due to chronic conjunctivitis, reaction to eye drops
- Post-traumatic stenosis (nasal fracture/surgery)
Clinical features, diagnostics, and complications are similar to those of congenital dacryostenosis.
Treatment
- Treatment of the underlying disorder
- Lacrimal duct probing/intubation: in all patients
- DCR: in refractory cases

References:^[2]^[7]^[8]^[9]^[10]^[11]^[12]

Dacryocystitis

	Acute dacryocystitis
Definition	Acute inflammation of the lacrimal sac
Etiology	Congenital/acquired dacryostenosis → stasis of tears → secondary bacterial infection → lacrimal sac inflammation
Clinical features	Erythema, edema, warmth, and significant pain below the medial canthus of the eye Pressure on the swelling causes pain and purulent discharge from the punctum. Epiphora Fever (may be present)
Diagnostics	Clinical Pus culture Blood culture: in patients with systemic symptoms (fever) Dacryocystography (DCG) : in patients with dacryostenosis secondary to trauma (altered anatomy) or suspected tumors (to locate the tumor)
Treatment	Symptomatic: warm compresses, NSAIDs Systemic antibiotics: Oral clindamycin, IV or oral amoxicillin + clavulanic acid, and IV vancomycin can be used empirically; culture-specific antibiotics are used once the report is ready Incision and drainage if lacrimal sac abscess occurs DCR (treatment of the NLD obstruction): after treating the infection

The lacrimal gland should not be probed during acute infection, since this may cause bacteria to spread to to other locations.

References:^[2]^[10]^[13]^[14]^[15]

References

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