• Clinical science

Diseases of the lacrimal apparatus

Abstract

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 Chronic dacryoadenitis
Definition
Etiology
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.
  • Can be unilateral or bilateral
  • Insidious onset with painless swelling over the lacrimal gland
  • S-shaped ptosis; proptosis rare
  • Features of underlying disease may be present (see “Etiology” above).
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
  • Eye swabs: in patients with ocular discharge
  • Screening for chronic infections (e.g., tuberculosis, Chlamydia trachomatis, gonorrhea)
  • CT scan: to rule out a malignant etiology
  • Fine needle/incisional biopsy of the lacrimal gland: indicated only if imaging/blood tests are inconclusive
  • Investigations based on the suspected etiology
Treatment
  • Viral dacryoadenitis may be self-limiting.
  • Broad-spectrum IV antibiotics: in febrile patients, presence of purulent discharge, positive blood/eye swab cultures
  • Treatment of the underlying disease

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

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
    • The tear film meniscus is wider in the affected eye.
    • 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
    • Fluorescein dye disappearance test: A time > 5 min for dye to disappear is diagnostic of NLD obstruction.
    • Lacrimal syringing: reflux of saline irrigated into the lacrimal punctum indicates NLD obstruction.
    • Lacrimal duct probing: to determine the site of the obstruction and recanalize the duct; a diagnostic and therapeutic procedure; indicated in infants with persistent epiphora despite lacrimal duct massage (see below)
  • Treatment: lacrimal sac massage; dilation or stenting of the duct; dacryocystorhinostomy if other measures fail
  • Complications (of untreated dacryostenosis): acute/chronic dacryocystitis

Acquired dacryostenosis

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

Dacryocystitis

Acute dacryocystitis Chronic dacryocystitis
Definition
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)
  • Epiphora
  • Mucopurulent discharge from the punctum
  • No signs of acute inflammation; no fever
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)
  • Clinical
  • Culture of the discharge
  • Investigations to confirm/locate NLD obstruction: NLD probing/syringing (see “Diagnostics” of dacryostenosis above); DCG
Treatment
Complications

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]

Lacrimal gland tumors

References:[2][10][16][17]