NCCPA™ PANCE Eyes, Ears, Nose, and Throat Content Blueprint eye disorders ⇒ lacrimal disorders
Lacrimal gland vs. lacrimal sac vs. lacrimal duct
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The lacrimal gland makes tears, while the lacrimal sac temporarily stores tears (made in the lacrimal gland), preventing them from constantly flooding the lacrimal ducts. The lacrimal duct, or the nasolacrimal duct, drains tears into the nasal cavity.
| Feature | Dacryostenosis | Dacryoadenitis | Dacryocystitis |
| Definition | Obstruction of the nasolacrimal duct | Inflammation of the lacrimal gland | Infection/inflammation of the lacrimal sac |
| Cause | Congenital or acquired duct obstruction | Viral or bacterial infection; rarely autoimmune | Bacterial infection (e.g., Staphylococcus, Streptococcus) |
| Onset | Gradual | Acute | Acute (often sudden) |
| Symptoms | Excessive tearing (epiphora), discharge, mild crusting | Swelling and pain in the upper eyelid, erythema, tenderness | Pain, redness, and swelling over the lacrimal sac (medial canthus), purulent discharge |
| Location | Nasolacrimal duct (medial canthus) | Lacrimal gland (upper outer eyelid) | Lacrimal sac (medial canthus) |
| Laterality | Unilateral or bilateral | Usually unilateral | Typically unilateral |
| Age Group | More common in infants (congenital cases) | All ages; more common in young adults | All ages, often in adults |
| Complications | Chronic tearing, secondary infection | Orbital cellulitis (rare) | Orbital cellulitis, abscess formation |
| Diagnosis | Clinical; fluorescein dye disappearance test may help | Clinical, sometimes imaging (e.g., CT orbit) | Clinical, may require imaging for abscess |
| Treatment | Lacrimal sac massage, warm compresses; probing or surgery if persistent | Warm compresses, treat underlying cause (antibiotics for bacterial, supportive for viral) | Oral/IV antibiotics, incision and drainage if abscessed |
| Prognosis | Excellent with proper management | Good with appropriate treatment | Good if treated promptly |
| Dacryoadenitis and Dacryocystitis | Dacryoadenitis
Patient with dacryoadenitis will present as → a 32-year-old woman presents to the emergency department with a 2-day history of pain, redness, and swelling in the outer corner of her right eye. She denies any vision changes, discharge, or trauma. She has no significant past medical history and is not on any medications. On physical examination, you note localized erythema and swelling over the lateral aspect of her right upper eyelid. Her visual acuity is normal, and there is no proptosis. Dacryoadenitis is the inflammation of the lacrimal (tear-producing) gland, commonly caused by infection (bacterial or viral) or systemic inflammatory conditions (supratemporal)
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:
Patient with dacryocystitis will present as → a 58-year-old woman presents to the emergency department with a 3-day history of increasing pain, redness, and swelling in the inner corner of her left eye. She also reports some purulent discharge from the same eye. She denies any vision changes or trauma. On physical examination, you note localized erythema, warmth, and swelling over the medial canthal area of her left eye. Her visual acuity is normal. Dacryocystitis is an infection or inflammation of the lacrimal sac, typically caused by obstruction of the nasolacrimal duct
DX:
TX:
 Left-sided dacryocystitis |
| Dacryostenosis (Nasolacrimal Duct Obstruction) | Patient will present as → a 6-week-old female presents with persistent tearing and yellowish discharge from the left eye since birth. The parents deny redness or swelling. Physical exam shows tearing, mucopurulent discharge, and a normal conjunctiva. Gentle pressure over the lacrimal sac produces discharge. The patient is diagnosed with dacryostenosis. Management includes lacrimal sac massage and topical antibiotic ointment if needed. Symptoms are expected to resolve by 6 to 12 months; persistent cases may require referral for nasolacrimal duct probing. Dacryostenosis is a condition characterized by the obstruction of the nasolacrimal duct, leading to excessive tearing (epiphora).
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
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| Keratoconjunctivitis sicca | The patient will present as → a 48-year-old woman who complains of chronic eye irritation, dryness, and a gritty sensation in both eyes. She notes that her symptoms worsen at night and after prolonged periods of reading or screen time. She reports mild discomfort with bright lights and occasional blurred vision. Her medical history includes rheumatoid arthritis. On examination, her eyes appear slightly reddened with decreased tear meniscus, and she blinks frequently. Given her symptoms and history of autoimmune disease, keratoconjunctivitis sicca (dry eye syndrome) is suspected. A Schirmer’s test reveals tear production of less than 5 mm in 5 minutes, confirming significantly reduced tear production. The patient is advised to use artificial tears frequently throughout the day and is prescribed an ophthalmic lubricating ointment for nighttime use. A follow-up visit is scheduled to monitor her response to therapy. Keratoconjunctivitis sicca, or dry eye syndrome, is characterized by chronic cornea and conjunctiva dryness due to insufficient tear production or increased tear evaporation
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, placing the strip in the lower eyelid pouch |
