What is Dacryoadenitis?
Dacryoadenitis is a condition where the lacrimal gland, which is situated at the top outer corner of the eye within the extra orbital fat, becomes inflamed. This can affect one or both eyes. The lacrimal gland, which has two sections separated by the outer part of an important eye muscle, can get inflamed due to infections or other inflammatory conditions, or sometimes for no known reason at all. If a virus causes the inflammation, it typically gets better by itself. However, if bacteria are the cause, antibiotics may be needed. Inflammation caused by other factors might get better with steroids, or need long-term treatment to keep the symptoms under control.
What Causes Dacryoadenitis?
Inflammation of the tear gland, also known as dacryoadenitis, can be either sudden (acute) or long-lasting (chronic). The acute type is often caused by infection and typically affects only one eye. The infection can come from the transparent part of the eye, the skin, or from a penetrating injury. It can also spread from the bloodstream during a bacterial infection. This condition tends to be caused more often by viruses than bacteria, especially in children and young adults. Common virus types include Epstein-Barr, adenovirus, mumps, herpes simplex, and herpes zoster.
When the inflammation is due to bacterial infection, pus often forms in the tear gland. The main bacteria that causes this is Staphylococcus aureus, but others like Streptococcus pneumoniae and certain damaging bacteria known as gram-negative rods can also cause it. In rare cases, fungi such as Histoplasma, Blastomyces, or Nocardia may be the culprits.
Chronic dacryoadenitis due to infection is less common, with most cases linked to a bacteria called Mycobacterium tuberculosis. However, chronic dacryoadenitis is typically caused by inflammatory conditions like Sjogren syndrome, sarcoidosis, Crohn’s disease, and granulomatosis with polyangiitis. Despite more understanding of these conditions and better testing, many cases of inflammation still cannot be traced to a specific cause, and are thus referred as idiopathic.
There is growing interest in a recently described condition known as IgG4-related dacryoadenitis. This condition has been noted to account for 23% to 35% of the cases of tear gland inflammation where the cause was previously unknown.
Risk Factors and Frequency for Dacryoadenitis
Dacryoadenitis is a condition that’s not as common as dacryocystitis, which is inflammation or infection of the tear sac. Kids and young adults are most often diagnosed with acute dacryoadenitis. When linked to an autoimmune disease, it’s seen more frequently in women than men, as is the case with most autoimmune diseases.
- Dacryoadenitis is less common than dacryocystitis (tear sac inflammation or infection).
- Acute dacryoadenitis usually affects children and young adults.
- When it’s related to an autoimmune disease, it more regularly appears in women than men.
Signs and Symptoms of Dacryoadenitis
Acute dacryoadenitis is a condition that usually presents itself with certain observable symptoms. These include redness and tenderness in the upper outer part of the eye socket, swelling that pushes down the outer part of the eyelids to form a characteristic S-shaped curve, and potential swelling of glandular and lymph nodes near the ear and in the neck. Additionally, there could be a discharge from tear ducts, a bulging of the tiny tear ducts, and swelling in the eyes. Fever and a general feeling of discomfort or illness may also be present. If dacryoadenitis is caused by inflammation, it could present as generally painless swelling of the tear glands and could affect both eyes.
- Redness and tenderness over the superior temporal (upper outer) part of the eye socket
- Swelling making the outer portion of the eyelid droop, creating an S-shaped curve
- Discharge from the tear ducts
- Bulging of tiny tear ducts
- Swelling in the eyes
- Swollen preauricular (near the ear) and cervical (in the neck) lymph nodes
- Fever and general discomfort or illness
- Potentially painless swelling of the tear glands (if inflammation is the cause)
- Be bilateral (affecting both eyes) if inflammation is the cause
Testing for Dacryoadenitis
If the swelling of the tear gland (also known as the lacrimal gland) occurs after catching a virus, it generally doesn’t require extensive testing or a biopsy. Nevertheless, if the swelling doesn’t go away with treatment, or if it presents unusual characteristics, we need to investigate further. Such features could include it happening in older people, affecting both sides of the face, or coming with symptoms that affect the whole body. These could be clues that the swelling could be related to cancer or a whole-body autoimmune condition.
If we suspect such conditions, a full range of tests might be necessary, including a complete blood count and tests for particular antibodies: anti-nuclear antibody (ANA) and anti-neutrophil cytoplasmic antibody (ANCA). We can also test for Sjogren syndrome by checking for anti-Ro and anti-La antibodies, although this test does not often lead to a diagnosis.
Imaging tests, such as CT or MRI scans, can help us get a better picture of the situation. They can reveal a distinct enlargement of the tear gland. They may also show inflammation of nearby muscles and tissues, which can be a sign of acute dacryoadenitis. Long-term (chronic) inflammation doesn’t usually involve these changes.
Biopsies, when a small tissue sample is extracted and studied under a microscope, might be required for cases of dacryoadenitis where its cause is unclear, its presentation is unusual, or it does not improve with treatment. A study found that 61.7% of cases where the cause of tear gland inflammation was not immediately apparent revealed specific pathological findings from a biopsy. Also, 38% of these cases turned out to be linked to systemic diseases. It’s suggested to avoid systemic steroids before the biopsy when possible.
While performing a biopsy, it’s important to sample the orbital lobe (part of the tear gland lying within the eye socket) to avoid harming the tear ducts. Once the tissue sample is collected, it’s usually preserved in a formalin solution, though some fresh tissue might be required for a specific test called flow cytometry. If you are getting a biopsy, your doctor will ensure the laboratory is prepared to receive the fresh and preserved tissue samples. Labs often have specific instructions for how to handle and transport these tissue samples, especially in the case of flow cytometry.
Treatment Options for Dacryoadenitis
Acute viral dacryoadenitis, an inflammation of the tear gland, usually gets better on its own within a month to a month and a half. It’s still unclear whether taking oral antiviral medications helps or not. If the inflammation is due to a bacterial infection, you’ll need antibiotics. It’s also smart to choose an antibiotic that will work against methicillin-resistant S. aureus, a type of bacteria that’s tougher to treat. If pus forms, a sample can be collected and tested in a lab to help choose the right antibiotic. In extreme cases, you might need surgical drainage to get rid of an abscess, or a pocket of pus.
Corticosteroids, a type of medication used to reduce inflammation, can help shrink an enlarged tear gland from almost any cause of dacryoadenitis. However, steroids shouldn’t be used just to diagnose the condition. One study suggests that some patients who have dacryoadenitis for no known cause may experience fewer symptoms with surgical debulking, a procedure that trims down the enlarged gland, and there’s less chance of the disease coming back. Tough-to-treat cases of inflammatory dacryoadenitis might be helped by orbital radiotherapy, a type of radiation treatment, or the drugs methotrexate or rituximab. A certain type of disease related to an immune system protein called IgG4 responds especially well to rituximab, but its effects might only be temporary.
The best approach to managing IgG4-related dacryoadenitis is still up for debate. Initial treatment with corticosteroids is generally a reasonable choice. Suppressing the immune system is only occasionally necessary. There have been cases where sclerosing dacryoadenitis, a type that causes scarring, that is linked to IgG4 has gone on to develop into lymphoma, a type of cancer.
Patients with dacryoadenitis that improves with treatment, but still have a lump in the tear gland after 3 months, should have a lacrimal gland biopsy, a procedure to collect a small sample of tissue for testing, after appropriate scanning.
What else can Dacryoadenitis be?
When an older patient has localized swelling of the tear gland, it’s crucial to rule out cancer. Certain types of cancer, like lymphoma, can infiltrate and expand the tear gland. They can range from mild (reactive lymphoid hyperplasia) to severely malignant conditions. Tumors, either benign or malignant, can also cause the tear gland to enlarge visibly in medical scans. Even certain epithelial tumors, like benign mixed tumors, adenoid cystic carcinoma, mixed malignant carcinoma, and mucoepidermoid carcinoma, can have a similar appearance.
Half of the time, this swelling happens due to an infection or inflammation, but in 25% of cases, it could be due to lymphoid tumors or salivary tumors.
It’s also worth noting that conditions like Thyroid eye disease (TED) can look similar to dacryoadenitis, a type of inflammation of the tear gland. A distinguishing factor is that TED typically results in the eyelid retracting, rather than a mild drooping, as seen in dacryoadenitis.
Other diseases causing redness, pain, and swelling around the eye must be taken into account. For example, cellulitis infection can affect the area around the eye, or sometimes specifically the eyelid might have a local swelling due to conditions like chalazion or hordeolum, but these do not cause true tear gland enlargement.
What to expect with Dacryoadenitis
Infections of the dacryoadenitis, a condition affecting the tear glands, might need antibiotics for treatment but usually get better without any issues. However, if dacryoadenitis is due to inflammation, it can be harder to treat and may depend on whether there are other underlying health problems. Treatment could involve a prolonged course of steroids, long-term therapy to regulate the immune system, or even surgery to remove part of the affected tissue.
If the inflammation keeps coming back or doesn’t go away, a biopsy (a procedure to remove and examine a small sample of tissue) might need to be repeated to determine the cause.
Possible Complications When Diagnosed with Dacryoadenitis
Although it’s uncommon, there can be problems from infectious dacryoadenitis. These issues might include the formation of an abscess in the lacrimal gland, which is a pocket of pus caused by the infection. The infection could also result in conditions like preseptal or orbital cellulitis, which are infections of the upper layers of skin around your eyes.
Preventing Dacryoadenitis
Patients suffering from an infection of the tear gland, known as infectious dacryoadenitis, should understand that this condition usually gets better on its own, although they might need to take antibiotics. They should closely observe any changes in their vision, experience of pain when moving their eyes, or signs of pus, as these could be signs of more serious problems like an infection in the eye socket (orbital cellulitis) or a pocket of pus (abscess). When the tear gland infection is due to an issue with the body’s immune system, patients should be informed about the possible disease and its potential impacts on the whole body. In such cases, they might need a gradual reduction in steroid medication or long-term treatment that helps regulate their immune system.