Lacrimal Gland Inflammation

Dacryoadenitis is inflammation of the lacrimal gland, acute or chronic.

• Acute infectious: viral (mumps, Epstein-Barr virus, cytomegalovirus, adenovirus, herpes zoster, coxsackie) in children and young adults; bacterial (Staphylococcus aureus, Streptococcus, Neisseria gonorrhoeae) with abscess formation.
• Chronic: idiopathic orbital inflammation, sarcoidosis, Sjogren syndrome, IgG4-related disease, granulomatosis with polyangiitis, thyroid eye disease, tuberculosis, syphilis, Crohn disease, and lymphoma (a mimic).
• Affects the palpebral and orbital lobes; the orbital lobe produces an S-shaped upper lid.

• Acute: painful swelling of the upper lateral lid with erythema, lateral ptosis giving an S-shaped lid margin, conjunctival injection and chemosis, lateral tenderness, preauricular lymphadenopathy, fever, and malaise.
• Mumps: parotitis. Bacterial: purulent discharge, sometimes with fluctuant abscess.
• Chronic: painless swelling for more than 1 month, sometimes bilateral (IgG4-related disease, sarcoid, lymphoma, Sjogren), proptosis, dry eye, diplopia.
• Systemic features: parotid enlargement and arthralgia (Sjogren), pulmonary symptoms (sarcoid), sinus disease and haematuria (granulomatosis with polyangiitis).

• Clinical examination with lid eversion to see the palpebral lobe.
• Blood tests: full blood count, ESR, CRP, ANA, anti-Ro/La, ANCA, ACE, calcium, serum IgG4, EBV and mumps serology, HIV, syphilis serology, tuberculosis testing (interferon gamma release assay), thyroid function.
• Imaging: CT or MRI orbits showing diffuse enlargement of the gland moulded to the globe with preserved shape (inflammation) versus nodular, indenting, bone eroding or calcified masses (tumours). Chest imaging for sarcoid and tuberculosis.
• Biopsy (incisional, of the orbital lobe) for chronic, atypical, bilateral, steroid refractory or suspicious cases to exclude lymphoma and carcinoma; avoid biopsy before imaging, and avoid biopsy of pleomorphic adenoma to prevent seeding.

• Viral: supportive, warm compresses, oral NSAIDs (ibuprofen 400 mg three times daily), self-limited over 1 to 4 weeks.
• Bacterial: oral amoxicillin clavulanate 625 mg three times daily for 7 to 10 days; intravenous cefazolin 1 g every 8 hours or ceftriaxone 1 to 2 g daily for severe disease; drain abscess surgically.
• Idiopathic or non-specific chronic: oral prednisolone 1 mg/kg daily (maximum 60 to 80 mg) for 1 to 2 weeks then taper over 6 to 8 weeks; steroid sparing agents (methotrexate 15 to 25 mg weekly, azathioprine 2 mg/kg daily, mycophenolate 1 g twice daily) or rituximab 1 g on days 1 and 15 for relapsing or IgG4-related disease. Radiotherapy 20 Gy in low dose fractions for refractory disease.
• Treat underlying systemic disease: sarcoid (prednisolone, methotrexate), granulomatosis with polyangiitis (cyclophosphamide or rituximab with high dose steroids), tuberculosis (standard four drug therapy for 6 months), syphilis (benzathine penicillin 2.4 million units intramuscularly weekly for 3 weeks if late latent).
• Lubricants for dry eye, and monitor for compressive optic neuropathy.
• Reassess within 2 weeks; failure to respond or recurrence demands a biopsy.