Notes to accompany tutorial presented in 03 Lacrimal Anomalies Module
Dr Simon Barnard PhD BSc FCOptom FAAO DCLP
Introduction
Lacrimal gland lies in the anterior lateral portion of the orbit in the lacrimal fossa
Large orbital portion (3 - 5 ducts) and smaller palpebral portion (5 - 7 ducts)
See 01 and 02 Anatomy notes for blood supply and innervation
Inflammations of the lacrimal gland
May be bilateral
ACUTE BACTERIAL DACRYOADENITIS
- Bacterial infections of lacrimal gland
- Often 2°
to trauma
- Presents with acute pain and ‘S’ shaped lid
- Treated with hot compresses and systemic antibiotics (e.g., erythromycin; penicillin)
ACUTE VIRAL DACRYOADENITIS
- Mildly acute viral infections of the lacrimal gland 2 °
to systemic viral infections (e.g., measles; mumps)
- Usually remits along with systemic infection
- Treat with hot compresses and analgesics
- Note: Aspirin contraindicated in children - increased risk of Reye’s syndrome
CHRONIC DACRYOADENITIS (MIKULICZ’S SYNDROME)
- A chronic enlargement of the lacrimal gland secondary to systemic disease and associated with enlarged salivary glands
- When associated with uveitis – known as HEERFORDT’S DISEASE
Symptoms and signs
- Persistent or progressive swelling of the outer one third of the upper eye lid
- Pain and / or double vision may or may not be present
- Chronic eyelid swelling and erythema - mostly outer 1/3rd of upper eyelid
- Possible proptosis and displacement of globe inferomedially
- Possible palpable mass
- EOM may be restricted
Sarcoidosis may be a possible cause in which case…
- May have concomitant lung, skin, or ocular disease
- Lymphadenopathy, parotid gland enlargement or VII N palsy may be present
- More common in blacks
Other causes include:
- Tuberculosis
- Syphilis
- Leukemia
- Mumps
ORBITAL INFLAMMATORY PSEUDOTUMOUR
- Often acute onset of pain and swelling with or without displacement of the globe and EOM restriction
- Respond well to systemic steroids
Tumours of the lacrimal gland
Clinical signs
- An enlarging lacrimal mass can produce proptosis together with inferomedial displacement of the eye
- "S" shaped lid
- Primary neoplasms (except lymphoma) are nearly always unilateral
Symptoms
- Epithelial malignancies of the gland are usually painful and progress more rapidly than benign epithelial neoplasms
- Benign mixed tumors have an insidious onset and produce chronic symptoms
- Symptoms of dry eye as the presenting system is rare (Char, 1989)
Classification of lacrimal gland tumours
BENIGN
Dermoid cyst
- Typically painless subcutaneous mass - a congenital ectodermal or mesodermal tumour
MALIGNANT
Malignant mixed epithelial tumours (Pleomorphic adenocarcinoma)
- Occurs primarily in elderly patients
- Acute pain
- Rapid progression
- May develop from benign adenoma
Mucoepidermoid carcinoma
Other anomalies
Lacrimal gland cyst (Dacryops)
- Asymptomatic
- Can fluctuate in size
- Typically occurs in a young or middle aged patient
Sjogren’s syndrome
- Chronic systemic inflammatory disorder characterised by xerostomia, dry eyes and other mucous membranes
- Often associated with rheumatic disorders having similar autoimmune features e.g., rheumatoid arthritis, scleroderma and systemic lupus erythematosus
- Atrophy of secretory epithelium in lacrimal glands
GENERAL INVESTIGATION
History
- Duration of anomaly, rate of progression, pain, tenderness, diplopia?
- Weakness, weight loss, fever or other signs of malignancy?
- Breathing difficulty, skin rash, history of uveitis? (? )SARCOIDOSIS)
Ocular examination
- KP, iris modules, posterior synechiae, or old retinal periphlebitis secondary to sarcoidosis
Orbital CT Scan (MRI rarely required)
Consider chest x-rays (Sarcoidosis/TB)
Systemic investigations by hematologist/oncologist
Lacrimal biopsy when a malignant tumour is suspected/diagnosis uncertain
Treatment
- Sarcoidosis - systematic steroids
- Orbital inflammatory pseudotumour - systematic steroids
- Benign and malignant mixed epithelial tumour- complete surgical removal
- Dermoid Cyst - complete surgical removal
- Lymphoid Tumour - orbital irradiation , plus systematic chemotherapy if systemic involvement
- Adenoid Cystic Carcinoma - orbital exenteration
- Lacrimal Gland Cyst - excise if symptomatic
References
Char D.H. (1989) Clinical Ocular Oncology, Churchill Livingstone, London