Dacryoadenitis : Introduction, Symptoms, Causes, Diagnosis, Management and Prevention - www.genericdrugscan.com

Dacryoadenitis : Information

Dacryoadenitis is an inflammation of the lacrimal gland. Dacryoadenitis may be acute or chronic.

Lacrimal gland is located in the superotemporal part of the orbit. It consists of two parts, palpebral lobe, which is visible on eversion of the eyelid and orbital lobe. Secretions of gland form the aqueous layer of the tear film. Dacryoadenitis may be infectious or has systemic aetiology.

Lacrimal gland belongs to the lymphoid tissue system and is called mucosa-associated lymphoid tissue (MALT). It contains Immunogobulin A (IgA) plasma cells, T cell lymphocytes and few B cell lymphocytes.

Dacryoadenitis often lacks the inflammatory signs and may present with enlargement only, then it has to be distinguished from the neoplasm of the gland.

References:

http://emedicine.medscape.com/article/1210342-overview

http://www.medscape.com/viewarticle/849552

http://www.reviewofophthalmology.com/content/d/features/i/1213/c/22862/

http://www.ncbi.nlm.nih.gov/pubmed/26247137

Kanski Jack J. Clinical Ophthalmology. A Systematic Approach. 6th ed. Butterworth, Heineman, Elsevier; 2008.

Symptoms at presentation depend upon whether the disease process is acute or chronic.

Acute dacryoadenitis: It may present acutely with:-

- Swelling of the lateral third of the upper lid.

- Pain in the lid with associated feeling of pressure in the eye.

- Redness of the lid.

- Conjunctival swelling.

- Conjunctival redness.

- Mucopurulent discharge from the eye.

- Swelling of the lymph nodes (submandibular).

- Bulging of the eyeball.

- Downward and inward displacement of the globe.

- Difficulty in eye movements.

Patient may have associated systemic features like fever, malaise, upper respiratory tract infection.

Chronic dacryoadenitis: Chronic dacryoadenitis has less severe presentation than acute dacryoadenitis. It is usually not associated with pain and the ocular signs are minimal. It may show:-

- Enlarged lacrimal gland which is mobile.

- Mild to severe features of dry eye.

The causes of lacrimal gland inflammation may be classified as:-

- Infectious.

- Idiopathic.

- Autoimmune.

- Lymphoproliferative.

Infectious dacryoadenitis: It may be:-

Viral dacryoadenitis: Viral dacryoadenitis is more common than bacterial, particularly in children and young adults. Viruses affecting lacrimal gland may be:-

- Epstein-barr and mumps viruses (common causative agents).

- Infectious mononucleosis.

- Adenovirus.

- Herpes zoster virus.

- Herpes simplex virus.

- Rhinovirus.

- Cytomegalovirus.

- Coxsackievirus A.

- Echovirus.

Bacterial dacryoadenitis: Acute suppurative bacterial dacryoadenitis is less common. Bacteria affecting lacrimal gland are:-

- Staphylococcus aureus.

- Streptococcus.

- Haemophilus influenzae.

- Klebsiella pneumoniae.

- Pseudomonas.

- Moraxella.

- Neisseria gonorrhoeae.

- Treponema pallidum.

- Mycobacterium leprae.

- Mycobacterium tuberculosis.

- Borrelia burgdorferi.

- Diptheroids.

- Micrococcus.

Fungal dacryoadenitis: It is rare and may be caused by:-

- Histoplasmosis.

- Blastomycosis.

Protozoal dacryoadenitis: It may rarely be caused by organisms like acanthamoeba.

Idiopathic dacryoadenitis:

Idiopathic is a nonspecific dacryoadenitis and is the most common histopathological diagnosis made for the lacrimal gland lesions. It causes inflammation and fibrosis in the gland. As the name suggests, the cause is unknown and bacterial or viral antigens are not identified. There is increased co-morbidity with autoimmune diseases that are not known to be related with lacrimal gland disease.

Autoimmune dacryoadenitis:

The lacrimal gland is often affected by autoimmune disorders and may be the first or only presentation. Lacrimal gland may be affected as:-

- Sarcoidosis dacryoadenitis.

- Sj gren s dacryoadenitis.

- Granulomatosis with polyangiitis (GPA) (Wegener granulomatosis) dacryoadenitis.

- Immunoglobulin G4-related (IgG4) dacryoadenitis.

- Lymphoplasmacytic dacryoadenitis (rare).

Inflammatory process in Graves disease and orbital inflammatory syndrome may also cause dacryoadenitis.

Lymphoproliferative dacryoadenitis:

Lymphoproliferative tumours may also cause orbital and lacrimal gland inflammation. Inflammation may be present in:-

- Lacrimal gland lymphoma.

- Reactive lymphoid hyperplasia.

Other epithelial neoplastic tumours like pleomorphic adenoma and adenoid cystic carcinoma may also show signs of inflammation.

Diagnosis is based on the clinical presentation of the patient and the supportive tests being conducted.

Patient may present with:-

In acute dacryoadenitis:

- There is usually unilateral, severe pain, associated redness with pressure sensation in superotemporal region of the eye.

- Acute and rapid onset of disease.

In chronic dacryoadenitis:

- Unilateral or bilateral painless enlargement of the lacrimal gland, may be present over a month, in superotemporal part of the eye.

This is more common than acute dacryoadenitis.

Examination of patient shows:-

In acute dacryoadenitis:

- Swelling of the lateral third of the upper lid (lid may assume S shape).

- Erythema or redness of the lid.

- Chemosis (conjunctival swelling).

- Conjunctival redness.

- Mucopurulent discharge from the eyes.

- Swelling of the lymph nodes (submandibular).

- Proptosis (bulging of the eyeball).

- Infero-medial displacement of the globe.

- Restriction of ocular movements.

Patient may have associated systemic features like fever, malaise, upper respiratory tract infection.

In chronic dacryoadenitis:

- Enlarged lacrimal gland which is mobile.

- Mild to severe features of dry eye.

- No tenderness over the swelling.

- Ocular signs are not there or are minimal.

Laboratory studies:

Acute dacryoadenitis: Following tests may be conducted in acute dacryoadenitis:-

- Examination of smear of discharge from the eye.

- Culture and sensitivity of the discharge from the eye.

- Blood culture.

Chronic dacryoadenitis: Chronic dacryoadenitis is usually associated with chronic systemic conditions. Test may be:-

- Lacrimal gland biopsy.

Imaging studies:

- Computerised tomography (CT) scan of the orbits with contrast medium may show oblong, diffuse enlargement of the lacrimal gland. There is marked enhancement in delineation with contrast medium in acute dacryoadenitis unlike chronic dacryoadenitis which does not show enhancement. Lacrimal gland changes may be bilateral in chronic dacryoadenitis unlike acute dacryoadenitis.

- No compressive changes in the contiguous bone or globe in CT scan. Compressive changes are usually present in lacrimal gland tumours.

Histopathologic examination of lacrimal gland:

Lacrimal gland biopsy is not indicated in acute dacryoadenitis.

Histopathological features of dacryoadenitis in certain diseases are:-

- Sarcoidosis: There is non-caseating granuloma with lymphocytic infiltration and fibrosis of acini.

- Graves disease: It shows lymphocytic infiltration, oedematous fibrous tissue and glandular degeneration.

- Sj gren s syndrome: This shows infiltration with lymphocytes and plasma cells.

- Granulomatosis with polyangiitis (Wegener granulomatosis): There is granulomatous inflammation with or without giant cells, collagen necrosis and vasculitis.

- IgG4 related dacryoadenitis: There is lymphoplasmacytic infiltration with lymphoid follicles often with reactive germinal centers, loss of acini, periductal and interlobular fibrosis. There are IgG4 positive plasma cells.

Dacryoadenitis should be distinguished from conditions like:

- Dry eye syndrome.

- Exophthalmos.

- Chalazion.

- Hordeolum.

- Preseptal cellulitis.

- Orbital cellulitis.

- Orbital dermoid.

- Lacrimal gland tumours.

Management of the disease should be under medical supervision.

Management depends upon the onset of disease process and its aetiology.

Acute dacryoadenitis:

- Viral dacryoadenitis: It is usually self-limiting and does not require any treatment. Supportive measures, such as non-steroidal anti-inflammatory medicine (NSAID), suffices.

- Bacterial dacryoadenitis: Broad spectrum antibiotics (such as cephalosporins) may be started with, awaiting culture report.

- Fungal dacryoadenitis: It may require anti-fungal agents.

- Protozoal dacryoadenitis: Specific antiamoebic may be prescribed.

Inflammatory non-infectious dacryoadenitis is investigated for systemic disease and is treated accordingly.

Chronic dacryoadenitis:

In chronic dacryoadenitis, underlying systemic disease is treated, which is guided by lacrimal gland biopsy.

Prognosis:

Acute dacryoadenitis: Acute dacryoadenitis is self-limited mostly and therefore carries a good prognosis.

Chronic dacryoadenitis: Prognosis depends upon the underlying disease and its management.