Diseases of the lacrimal apparatus

Last updated: January 25, 2022

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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).

Acute dacryoadenitis Chronic dacryoadenitis
Definition
Etiology
Clinical features
  • 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
Treatment
  • Treatment of the underlying disease

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
  • Diagnostics: clinical diagnosis; syringing or probing of the duct to determine the site of obstruction and remove the obstruction, if necessary
    • 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)
      • The lacrimal punctum is dilated and a flexible metallic probe is inserted into the NLD. If the probe encounters an obstruction, this confirms the diagnosis.
      • Light pressure on the probe breaks through any obstruction and recanalizes the NLD.
      • Presence of ocular infection is a contraindication to probing.
  • 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]

Acute dacryocystitis
Definition
Etiology
Clinical features
Diagnostics
  • Clinical
  • Pus culture
  • Blood culture: in patients with systemic symptoms (fever)
  • Dacryocystography (DCG)
    • A contrast imaging of the lacrimal sac and NLD
    • Performed in patients with dacryostenosis secondary to trauma (altered anatomy) or suspected tumors (to locate the tumor)
Treatment

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

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

References:[2][16][17]

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  8. Lacrimal Sac (Dacryocystitis). https://www.aao.org/bcscsnippetdetail.aspx?id=67a46135-ad69-4533-8ddc-c0e3663dd87a. . Accessed: May 18, 2017.
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  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. 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
  17. 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.
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