April 01, 2007
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Woman referred for swelling, irritation in right eye

On examination, the lacrimal gland appeared enlarged and swollen, and there was purulent discharge and crusting on the lids and lashes.

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Grand Rounds at the New England Eye Center

A 64-year-old African-American woman was referred from an outside ophthalmologist for periorbital swelling and a red, irritated right eye for 2 days.

The patient noted swelling beginning in the outer corner of her right upper eyelid. Swelling progressively worsened and was accompanied by photophobia, tearing and matted eye lashes. She experienced pain only when she touched her lids. She denied any significant visual changes. She had no history of recent upper respiratory symptoms, sick contacts, recent trauma or lid surgery.


Shazia Ahmed

My Hanh T. Nguyen

Her medical and ocular histories were unremarkable. She denied taking any systemic or ocular medications and had no known drug allergies. Family history was noncontributory, and a review of systems was positive for a bout of bronchitis several months before. The patient admitted to smoking one pack of cigarettes every couple of days and drinking on social occasions.

Examination

The patient’s vision without correction was 20/60 in the right eye and 20/50 in the left eye. With pinhole, vision improved to 20/30 in both eyes. Her pupils were equal and reactive to light without a relative afferent pupillary defect. Pressures were measured by applanation and were within normal limits. She had limitation of abduction in the right eye, but otherwise extraocular movements were full. Visual fields were full to confrontation in both eyes.

Anterior slit lamp exam revealed extensive periorbital edema and erythema of the right eye with purulent discharge and crusting on the lids and lashes. The right eye appeared injected and chemotic. There was a tender, mobile nodule on the right upper lid located laterally and just inferior to the brow (Figure 1). Upon lid eversion, the lacrimal gland appeared enlarged and swollen. The patient had no palpable pre-auricular or submandibular lymph nodes and no enlargement of the parotid gland. There was mild nuclear sclerosis and cortical changes in both lenses. Dilated fundus examination was remarkable only for extrafoveal drusen in both eyes. A CT scan showed diffuse enlargement and loculated appearance of the lacrimal gland (Figures 2 to 4).


Color photo of affected right eye showing lid swelling, purulent discharge, conjunctival injection and chemosis.


Axial cuts of orbital CT with contrast showing enlarged, loculated lacrimal gland right orbit.


Orbital CT with contrast, coronal slice showing loculation of lacrimal gland right orbit.


Orbital CT with contrast, saggital view showing enlarged lacrimal gland with contrast uptake.

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What is your diagnosis?

Swollen lacrimal gland

Given the purulent discharge and swollen lacrimal gland, the patient was given a presumptive diagnosis of acute infectious dacryoadenitis. The differential diagnosis of periorbital swelling and erythema includes infectious causes such as preseptal and orbital cellulitis; inflammatory causes such as thyroid eye disease, sarcoidosis and orbital pseudotumor; and neoplastic causes such as lymphoma and benign or malignant lacrimal gland tumors. The clinical presentation may also be mistaken for a chalazion or a hordeolum.

Treatment

The patient was started on oral Keflex (cephalexin, Dista) 250 mg four times per day. She experienced significant improvement in her symptoms, and the lacrimal gland swelling diminished over several office visits.

Discussion

Dacryoadenitis is an inflammatory enlargement of the lacrimal gland. It can be acute or chronic. Acute dacryoadenitis can be caused by a systemic inflammatory process, a viral or bacterial infection, or an idiopathic process. Chronic dacryoadenitis may be secondary to an indolent infection (ie, TB, trachoma, fungal), a systemic inflammatory condition, or a benign or malignant neoplastic process.

The lacrimal gland is located in the superotemporal orbit in the lacrimal fossa. It is a bi-lobed structure with an orbital and palpebral lobe. The palpebral lobe can be visualized by eversion of the upper lid. The lacrimal gland is an eccrine secretory gland that secretes the aqueous layer of tear film. Infectious dacryoadenitis is thought to be caused by the inciting agent ascending from the conjunctiva through the lacrimal ductules into the lacrimal gland. It is an uncommon condition, estimated to occur in one in 10,000 people. Inflammatory enlargement is much more common than lacrimal gland tumors. Acute dacryoadenitis tends to be a self-limited condition while chronic dacryoadenitis requires management of the underlying systemic condition. There is no specific predilection for race, gender or age.

Acute dacryoadenitis presents as rapid onset of unilateral redness and swelling in the supratemporal region of the orbit. In contrast, chronic dacryoadenitis can be bilateral, painless and present for more than 1 month. It is more common than acute dacryoadenitis. On physical exam, findings of acute dacryoadenitis include prolapsed and enlarged palpebral lobe on lid eversion, swelling of the lateral third of upper lid (S-shaped lid), conjunctival injection, chemosis, mucopurulent discharge, submandibular lymphadenopathy, proptosis and ocular motility restriction. These findings can be associated with parotid gland enlargement, fever, upper respiratory infection and malaise. Chronic dacryoadenitis tends to have a less severe presentation than acute. Pain is usually absent with an enlarged, mobile gland and minimal ocular signs.

For acute dacryoadenitis, cultures should be taken if purulent discharge is present. In addition, blood cultures and immunoglobulin titers to specific viruses are indicated if systemic illness is present. For chronic dacryoadenitis, a screen for chronic systemic conditions is indicated. A lacrimal gland biopsy may provide useful information. Screens for syphilis, tuberculosis and trachoma should also be considered.

Treatment for acute dacryoadenitis is determined by the cause. For viral etiologies, inflammation is usually self-limited. Cool compresses and NSAIDs can give symptomatic relief. A first-generation cephalosporin should be initiated for bacterial dacryoadenitis until cultures come back. Inflammatory causes should prompt a systemic workup. If the etiology of the acute dacryoadenitis is unclear, initiating treatment with an oral antibiotic and then adding an oral steroid if no improvement is observed is often a judicious course of action. Treatment for chronic dacryoadenitis includes treatment of any underlying systemic condition. If enlargement of the lacrimal gland persists beyond 2 weeks or the diagnosis is unknown, a biopsy of the gland should be considered.

Table 1
Causes of dacryoadenitis

Infectious
Viral (most common): mumps, EBV, Herpes zoster, mononucleosis, CMV, echoviruses, coxsackievirus A
Bacterial: Staphalococcus aureus, Streptococcus, Neisseria gonorrhoeae, Treponema pallidum, Chlamydia trachomatis, Mycobacterium leprae, Mycobacterium tuberculosis
Fungal (rare): Histoplasmosis, blastomycosis
Parasite (rare): Schistosoma haematobium

Inflammatory
Sarcoidosis
Graves’ disease
Sjögren’s syndrome
Orbital inflammatory syndrome (orbital inflammatory pseudotumor)
Benign lymphoepithelial lesion

Neoplasm
Benign mixed epithelial tumor (pleomorphic adenoma)
Dermoid
Lymphoid tumor
Adenoid cystic carcinoma
Malignant mixed epithelial tumor (pleomorphic adenocarcinoma)
Lacrimal gland cyst (dacryops)
Other: leukemia, mucoepidermoid carcinoma, plasmacytoma

Source: Balderas I, Heher K

For more information:
  • Isabel Balderas, MD, and Katrinka Heher, MD, can be reached at New England Eye Center, Tufts University School of Medicine, 750 Washington St., Box 450, Boston, MA 02111; 617-636-4219; fax: 617-636-4866; Web site: www.neec.com.
  • Edited by Shazia Ahmed, MD, and My Hanh T. Nguyen, MD. Drs. Ahmed and Nguyen can be reached at New England Eye Center, Tufts University School of Medicine, 750 Washington St., Box 450, Boston, MA 02111; 617-636-4219; fax: 617-636-4866; Web site: www.neec.com. Drs. Ahmed and Nguyen have no direct financial interest in the products mentioned in this article, nor are they paid consultants for any companies mentioned.
References:
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  • Brindley GO. Dacryoadenitis. In: Linberg JV, ed. Oculoplastic and Orbital Emergencies. Norwalk, Conn.: Appleton & Lange; 1990:45-50.
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  • Jakobiec FA, Yeo JH, et al. Combined clinical and computed tomographic diagnosis of primary lacrimal fossa lesions. Am J Ophthalmol. 1982;94(6):785-807.
  • Massaro BM, Tabbara KF. Infections of lacrimal apparatus. In: Tabbara KF, Hyndiuk RA, eds. Infections of the Eye. Boston: Little Brown & Co; 1996:551-558.
  • Podos SM, Yanoff M. Acute dacryoadenitis. In: Textbook of Ophthalmology – External Disease. Europe: Mosby-Year Book; 1994:1414-1416.