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Dacryoadenitis is the inflammation of the lacrimal (tear-producing) gland, commonly caused by infection (bacterial or viral) or systemic inflammatory conditions (supratemporal)

• Causes include:
  • Acute dacryoadenitis is typically due to bacterial (Staphylococcus, Streptococcus) or viral infections (e.g., mumps, Epstein-Barr virus)
  • Chronic dacryoadenitis is associated with systemic conditions like sarcoidosis, Sjögren’s syndrome, or thyroid eye disease
• Presents with unilateral, painful swelling of the outer upper eyelid (seen here), with redness, tenderness, and sometimes proptosis or restricted eye movement
• Chronic cases are usually painless and associated with gradual swelling

DX: The diagnosis is based on clinical observation, but imaging (e.g., CT or MRI) can confirm lacrimal gland involvement and rule out abscess or neoplasm

TX:

Acute treatment involves:

• • Antibiotics for bacterial causes (e.g., cephalexin or amoxicillin-clavulanate)
  • Supportive care for viral causes (e.g., warm compresses, analgesics)
• Chronic treatment focuses on managing the underlying systemic condition
• Surgical drainage may be needed for abscess formation, and biopsy may be required in chronic or atypical cases to exclude malignancy
• Complications include lacrimal gland abscess, vision impairment, or progression to orbital cellulitis

Dacryoadenitis presenting as an erythematous, swollen upper eyelid and ptosis. From "Dacryoadenitis with Ptosis and Diplopia as the Initial Presentation of Granulomatosis with Polyangiitis" by Makoto Hibino and Tetsuri Kondo via ResearchGate. Licensed under CC BY-NC-ND 4.0.

Dacryocystitis

Dacryocystitis is an infection or inflammation of the lacrimal sac, typically caused by obstruction of the nasolacrimal duct

• Common causes include Staphylococcus aureus, Streptococcus species, and, less commonly, Gram-negative bacteria
• Risk factors include nasolacrimal duct obstruction, sinus infections, and trauma to the lacrimal system
• Symptoms include pain, swelling, erythema, and tenderness over the inner aspect of the lower eyelid near the lacrimal sac, often accompanied by tearing (epiphora) and discharge

DX:

• In acute cases of dacryocystitis, a tear duct massage can be performed to express material for culture and gram stain
• In patients who appear to be acutely toxic or those who present with visual changes, imaging (CT), and bloodwork should be considered

TX:

• Warm compresses and gentle massage may help alleviate symptoms
• Acute dacryocystitis (< 3 months) requires oral antibiotics (e.g., cephalexin or amoxicillin-clavulanate) for mild cases and IV antibiotics for severe infections or systemic involvement
• Chronic dacryocystitis (> 3 months) typically presents with fewer inflammatory signs and requires surgical therapy for the underlying cause
• Definitive treatment involves addressing the underlying obstruction, often with dacryocystorhinostomy (DCR), a surgical procedure to restore tear drainage
• Complications include abscess formation, orbital cellulitis, and, rarely, sepsis

Dacryocystitis with swelling and inflammation over the lacrimal sac. Photo by Natanalyzator via Wikimedia Commons, CC BY-SA 4.0.

CT showing dacryocystitis with inflammation of the lacrimal sac adjacent to the medial orbit (arrow). Photo by James Heilman, MD via Wikimedia Commons, CC BY-SA 4.0.

Dacryostenosis is a condition characterized by the obstruction of the nasolacrimal duct, leading to excessive tearing (epiphora).

• Most common cause of persistent tearing in infants, usually due to incomplete canalization of the nasolacrimal duct at birth
• In adults, it can result from infection, trauma, inflammation, or age-related narrowing of the duct
• Presents with chronic tearing, crusting of the eyelids, and occasionally recurrent conjunctivitis

DX: Diagnosis is clinical, based on symptoms and examination showing a blocked tear drainage system; additional tests like fluorescein dye disappearance test may help confirm obstruction

TX: Initial management in infants involves lacrimal sac massage (Crigler maneuver) and monitoring, as many cases resolve spontaneously by 6-12 months

• Persistent cases or adult-onset dacryostenosis may require probing, balloon catheter dilation, or stenting of the nasolacrimal duct
• Dacryocystorhinostomy (DCR) is the definitive surgical treatment for severe or refractory cases, creating a new drainage pathway into the nasal cavity
• Complications include recurrent infections such as dacryocystitis and chronic conjunctivitis if untreated

Dacryostenosis (Blocked Tear Duct)

Keratoconjunctivitis sicca, or dry eye syndrome, is characterized by chronic cornea and conjunctiva dryness due to insufficient tear production or increased tear evaporation

• Common causes include autoimmune diseases, aging, certain medications, and environmental factors like prolonged screen exposure
• Symptoms typically involve dryness, burning, and blurred vision, often worsening at night or after extended screen use

DX:  Relies on clinical symptoms and tests like Schirmer's Test, Tear breakup test (TBUT), and fluorescein staining

TX:  Include artificial tears, anti-inflammatory eye drops, environmental modifications, and punctal plugs to relieve symptoms and prevent complications like corneal ulcers or vision impairment

Schirmer's test demonstrating the placement of the strip in the lower eyelid pouch. Created by Jmarchn via Wikimedia Commons. Licensed under CC BY-SA 3.0.