Diseases of the lacrimal apparatus

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).

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

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

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]}

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]}

1. Bowling B. Kanski's Clinical Ophthalmology E-Book: A Systematic Approach. Elsevier Health Sciences ; 2015
2. Fraunfelder FT. Roy and Fraunfelder's Current Ocular Therapy. Elsevier Health Sciences ; 2008
3. Derr C, Shah A. Bilateral dacryoadenitis. J Emerg Trauma Shock. 2012; 5 (1): p.92-94. doi: 10.4103/0974-2700.93096 . | Open in Read by QxMD
4. Unraveling the Difficult Diagnosis of Dacryoadenitis. https://www.reviewofophthalmology.com/article/unraveling-the-difficult-diagnosis-of-dacryoadenitis. Updated: August 13, 2009. Accessed: May 17, 2017.
5. Zoukhri D. Effect of inflammation on lacrimal gland function. . Exp Eye Res. 2006; 82 (5): p.885-898. doi: 10.1016/j.exer.2005.10.018 . | Open in Read by QxMD
6. Singh GJ. Dacryoadenitis. In: Roy H, Dacryoadenitis. New York, NY: WebMD. http://emedicine.medscape.com/article/1210342. Updated: March 9, 2015. Accessed: May 17, 2017.
7. Paysse EA, Coats DK. Congenital Nasolacrimal Duct Obstruction (Dacryostenosis) and Dacryocystocele. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/congenital-nasolacrimal-duct-obstruction-dacryostenosis-and-dacryocystocele.Last updated: May 27, 2015. Accessed: May 18, 2017.
8. Lacrimal Sac (Dacryocystitis). https://www.aao.org/bcscsnippetdetail.aspx?id=67a46135-ad69-4533-8ddc-c0e3663dd87a. . Accessed: May 18, 2017.
9. Pinar-Sueiro S, Sota M, Lerchundi TX et al. Dacryocystitis: systematic approach to diagnosis and therapy. Curr Infect Dis Rep. 2011; 13 (5). doi: 10.1007/s11908-012-0238-8 . | Open in Read by QxMD
10. Udhay P, Noronha OV, Mohan RE. Helical computed tomographic dacryocystography and its role in the diagnosis and management of lacrimal drainage system blocks and medial canthal masses. Indian J Ophthalmol. 2008; 56 (1): p.31-37.
11. Toker E, Yenice O, Oğüt MS, Akman I, Ozek E. Tear production during the neonatal period. Am J Ophthalmol. 2002; 133 (6): p.746-749.
12. Diagnostic Tests. https://www.aao.org/bcscsnippetdetail.aspx?id=78f9774f-1515-4b00-9ab2-bdce57fd14d3. . Accessed: May 18, 2017.
13. Joseph JM. Lacrimal System Probing and Irrigation. In: Ing E, Lacrimal System Probing and Irrigation. New York, NY: WebMD. http://emedicine.medscape.com/article/1844121. Updated: March 3, 2017. Accessed: May 18, 2017.
14. Nasolacrimal Duct Obstruction, Congenital. http://eyewiki.aao.org/Nasolacrimal_Duct_Obstruction,_Congenital. Updated: May 7, 2017. Accessed: May 18, 2017.
15. Dacryostenosis. http://www.merckmanuals.com/professional/eye-disorders/eyelid-and-lacrimal-disorders/dacryostenosis. Updated: July 1, 2016. Accessed: May 18, 2017.
16. Grehn F. Augenheilkunde. Springer Verlag (2005) ; 2006
17. Lang GK, et al.. Augenheilkunde. Thieme Verlag (2008) ; 2008
18. Gao Y, Moonis G, Cunnane ME, Eisenberg RL. Lacrimal Gland Masses. AJR. 2012; 201 . doi: 10.2214/AJR.12.9553 . | Open in Read by QxMD
19. Diagnosis & Treatment of Lacrimal Gland Neoplasias. https://www.reviewofophthalmology.com/article/diagnosis-treatment-of-lacrimal-gland-neoplasias. Updated: April 5, 2013. Accessed: May 18, 2017.