What Is Dacryoadenitis?

  • Alessia ZappaIntegrated Masters, Biomedical Sciences, University of York
  • Cynthia Chen MSc of Biochemical Engineering (2023)
  • Yuna Chow BSc (Hons), Medicine, University of St Andrews

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Dacryoadenitis is the inflammation of one or both of your lacrimal glands (where watery tears are produced), which typically leads to swelling on the outer corner of your upper eyelids. This inflammation is caused by either an infection (virus, bacteria or fungi) or as a result of having an autoimmune disease.1

This article will detail the symptoms, types and causes of dacryoadenitis, as well as the diagnostic methods and treatments used to deal with this inflammation. 

What are lacrimal glands?

In order to fully understand dacryoadenitis, let us first consider where and what the lacrimal glands are, and why they are so important. 

The lacrimal glands are located on the outside corner of the upper eyelids, just above the eyeballs. These glands are shaped almost like a tear and are roughly the size of an almond.2 They play an essential role in the production of watery tears, which not only form when we cry but are also crucial in keeping the eyes healthy.3 

Tears have 3 layers, each with its own important function: 

  • Outer oily layer - essential in preventing the other layers of the tear from evaporating from the eye. It also aids in providing a smooth service on the top of the eye, which in turn helps facilitate clearer vision4 
  • Middle watery (aqueous) layer - the thickest layer of the tear. This layer has the crucial role of hydrating and nourishing the eye with proteins, electrolytes and water. This helps the eye continue to function as it should. This watery layer also keeps any germs away from the cornea (the transparent front part of the eye)4
  • Inner mucin layer - helps tears stick to the eyes, so they can continue to protect the eyes and keep them healthy4

The lacrimal glands are specifically in charge of producing the middle watery layer of the tear.3 If something irritates these glands, they can begin to swell. Dacryoadenitis is the medical name for this inflammation.1

Signs and symptoms of dacryoadenitis

Dacryoadenitis can lead to a variety of symptoms, the most typical ones including:5

  • Significant swelling of the glands, which leads to the swelling of the skin around the upper outside corner of your eye. Due to this swelling, the eyelid may droop (termed ptosis) or become red/discoloured, and it might become painful to move it
  • Swollen lymph nodes located near the ears
  • Due to the inflated gland, its function can also be affected. More tears may be produced than normal, which can make the eye constantly watery. This is called epiphora. The opposite of epiphora could also happen, where instead the lacrimal gland cannot secrete any watery tears due to its swelling. This can make the eyes particularly dry, and this is called aqueous tear deficiency
  • Although it is uncommon for dacryoadenitis to affect the ability to see, sometimes the swelling can be so severe that it puts pressure on the eyes and impairs vision

Types and causes of dacryoadenitis

Dacryoadenitis can be caused by a wide variety of conditions, which can be typically categorised as either an infection or an autoimmune disease. Based on its cause, dacryoadenitis can be classified into two different types.5

Acute dacryoadenitis (caused by infections)

Dacryoadenitis can be caused by an infection that manages to get into the eye. This infection occurs when either a virus, bacteria or on rare occasions fungi enters the eye through the conjunctiva (the thin layer of the eye that lines the inside of the eyelids and covers the white sclera of the eyes).

These infections can also be a result of any trauma or injury (such as a cut) endured on the skin close to the lacrimal gland. When this occurs, dacryoadenitis is classified as acute. This acute infection typically only affects one of the eyes (known as unilateral dacryoadenitis).1

The most common infections that cause acute dacryoadenitis include:5

Chronic dacryoadenitis (caused by autoimmune diseases)

Dacryoadenitis can also be a consequence of a patient having an autoimmune disease. An autoimmune disease is the result of the body’s immune system attacking its own cells and organs, including lacrimal glands, instead of protecting them. When this occurs, dacryoadenitis is classified as chronic. This chronic inflammation typically affects both eyes at the same time (known as bilateral dacryoadenitis).7

Autoimmune diseases that can cause chronic dacryoadenitis include:7

  • IgG4-related autoimmune disease - a specific autoimmune disease that has shown to cause a significant proportion of chronic dacryoadenitis. IgG4 is an antibody that plays the essential role of identifying harmful foreign substances in the body, such as viruses and bacteria, and alerting other cells in the immune system to attack and destroy them before they can cause harm. People who have IgG4-related autoimmune disease have abnormally high levels of IgG4, and these high levels can in turn harm the body’s own organs, instead of protecting them. One of the outcomes includes the attacking and swelling of the lacrimal gland, leading to chronic dacryoadenitis8
  • Sjögren syndrome 
  • Sarcoidosis
  • Thyroid eye disease
  • Granulomatosis with polyangiitis 

Diagnosis

If you suspect you have dacryoadenitis (if you are experiencing any of the symptoms listed above, particularly pain and swelling in the upper corner of your eye), then you should visit an eye care specialist. They will then do a series of tests to correctly diagnose dacryoadenitis.9

These tests include:

  • Physical examination - an eye care specialist will perform a physical examination of your infected eye(s) and surrounding tissue to assess physical signs and symptoms
  • Medical history - the patient’s medical history is explored in order to evaluate whether any past medical problems could have led to dacryoadenitis (such as past infections or the presence of autoimmune disease)
  • Imaging studies - imaging tests (such as an MRI or a CT scan) take pictures of the inside of the eye, including inflamed lacrimal glands and surrounding tissue 
  • Blood tests - to assess what is causing the dacryoadenitis (for instance to check for the presence of an infection, or to check levels of IgG4)
  • Biopsy - they can also surgically remove a small part of your inflamed lacrimal gland (procedure being termed biopsy) to properly assess the tissue of the gland. They commonly do this procedure if they suspect that the inflammation could be something more serious, such as a tumour

Differential diagnosis 

Dacryoadenitis can be easily confused with other eye conditions. One of the main examples is a condition that has a very similar sounding name - dacryocystitis. Both conditions affect parts of the tear system. The difference between the two is where the inflammation happens.

Unlike dacryoadenitis, dacryocystitis does not affect the lacrimal glands, but instead causes inflammation to the lacrimal sacs. These sacs are found in the inside corner of your eyes, and their role is to collect tears before they drain into your tear ducts and fall onto your face.

Blocked tear ducts are the most common cause of dacryocystitis.10 A physical examination by an eye care specialist will help the differential diagnosis of the two.

Other conditions with which dacryoadenitis can be confused include malignant masses (tumours) around the lacrimal gland. These masses have the same symptoms as dacryoadenitis, but are obviously much more harmful.

Examples of such masses that mimic dacryoadenitis include lymphoma, melanoma, pleomorphic adenoma and adenoid cystic carcinoma. If an eye care specialist suspects your dacryoadenitis is actually a malignant lesion, then a biopsy will be carried out.9 

Management and treatment for dacryoadenitis

How dacryoadenitis is treated is dependent on what is causing the inflammation. The most common treatments used include the following: 

  • Antibiotics to cure bacterial infections5 
  • Antiviral medications to cure viral infections5
  • Warm compresses placed on the affected eye(s)11 
  • Corticosteroids can be prescribed to shrink the inflammation and swelling of the lacrimal gland5 
  • In rare cases where the swelling does not go down after a couple of months, or when the cause of the inflammation is unknown (known as idiopathic), surgical debulking can be done. This is the process of reducing as much of the swelling of the lacrimal gland as possible, without completely getting rid of the gland itself12
  • For chronic dacryoadenitis, one of the most effective treatments is to manage the autoimmune disease that is in turn causing dacryoadenitis. Such management is dependent on the autoimmune disease, and hence a healthcare specialist will direct you to appropriate treatments9

Prognosis of dacryoadenitis

With proper treatment, most acute dacryoadenitis patients make a full recovery from the inflammation in 4-6 weeks following initial swelling.5 Complications with acute dacryoadenitis are rare, but sometimes they can happen.

Such complications include the build-up of pus in the inflamed lacrimal gland (termed lacrimal gland abscess), and preseptal and orbital cellulitis (inflammation of the eyelid under the eye).5 These can be addressed through further treatments recommended by an eye care specialist. 

Regarding chronic dacryoadenitis, although most patients also make full recovery, symptoms are more likely to recur compared to acute dacryoadenitis. If symptoms do not resolve by 3 months, a biopsy will most likely be done to assess how to treat the inflammation.13

FAQs

How can I prevent dacryoadenitis?

The best ways to prevent the development of acute dacryoadenitis include the following: 

  • Washing your hands frequently (with soap and clean, running water, for at least 20 seconds), particularly before you touch your eyes - this will avoid any germs entering your eyes 
  • Avoiding contact with individuals who have dacryoadenitis, as they could be contagious 
  • For certain viral infections that are known to cause dacryoadenitis, such as mumps, getting vaccinated against it will prevent any swelling of the lacrimal gland - as your body is equipped and prepared to fight off this infection before it can cause any subsequent swelling

When it comes to chronic dacryoadenitis, it is impossible to prevent it, as it is difficult to prevent developing an autoimmune disease.

Who is at risk of developing dacryoadenitis?

You are at risk of developing dacryoadenitis if you have an autoimmune disease, or if you have been exposed to a virus, bacteria or fungi that has then managed to get into your eye. Particularly, dacryoadenitis has been found to be more common in children and young adults than adults above the age of 50.1 

Chronic dacryoadenitis is more common in people assigned female at birth (AFAB). This is because autoimmune diseases tend to be more common in these people.14 

When should I see a doctor?

You should visit an eye care specialist if you notice any pain or swelling around the upper outer corner of your eyelid(s), or if you are experiencing any changes in your vision. 

If you are experiencing any of the following symptoms however, you must instead go to the hospital:

  • Sudden swelling of your eyelid that worsens quickly
  • Severe pain in the eye 
  • New and frequent floaters and flashes in your eyes 
  • A sudden loss in your vision

Summary

Dacryoadenitis is the inflammation of one or both of your lacrimal glands, which are found near the upper outside corners of your eyes and responsible for making your tears watery. Defining symptoms include swelling, pain, and discolouration of the upper outside corner of your eye(s), which can sometimes lead to a drooping eyelid and problems with your tear production (your eyes can either become too watery, or overly dry).

There are two main classes of dacryoadenitis: acute (caused by viral, bacterial or fungal infections) and chronic (caused as a consequence of an autoimmune disease). If you are experiencing any of the defining symptoms of dacryoadenitis, it is advisable to visit an eye care specialist who will prescribe you the appropriate treatment.

With correct medication, dacryoadenitis generally clears up within 4-6 weeks. It is important to note that chronic dacryoadenitis may come back even after treatment, due to the ongoing autoimmune disease. When this occurs, your healthcare provider will help you manage your autoimmune disease and any recurring dacryoadenitis symptoms.

References

  1. Mafee MF, Haik BG. Lacrimal gland and fossa lesions: role of computed tomography. Radiol Clin North Am. 1987 Jul;25(4):767–79.
  2. Machiele R, Lopez MJ, Czyz CN. Anatomy, head and neck: eye lacrimal gland. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Nov 2]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK532914/
  3. Pflugfelder SC, Stern ME. Biological functions of tear film. Exp Eye Res. 2020 Aug [cited 2023 Nov 2];197:108115. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483968/
  4. Dartt D, Willcox M. Complexity of the tear film: Importance in homeostasis and dysfunction during disease. Exp Eye Res. 2013 Dec [cited 2023 Nov 2];117:1–3. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4225770/
  5. Patel R, Patel BC. Dacryoadenitis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Nov 2]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK535384/
  6. Rhem MN, Wilhelmus KR, Jones DB. Epstein-Barr virus dacryoadenitis. Am J Ophthalmol. 2000 Mar;129(3):372–5.
  7. Durand ML. 118 - Periocular Infections. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases (Eighth Edition). Philadelphia: W.B. Saunders; 2015 [cited 2023 Nov 2]. p. 1432-1438.e2. Available from: https://www.sciencedirect.com/science/article/pii/B9781455748013001181
  8. Lee FJ et al. IgG4-related Dacryoadenitis. Ophthalmology. 2010 Feb [cited 2023 Nov 2];117(2);398. Available from: https://www.aaojournal.org/article/S0161-6420(09)01049-5/fulltext
  9. Fla MW MD, Tampa. Unraveling the difficult diagnosis of dacryoadenitis. [cited 2023 Nov 2]. Available from: https://www.reviewofophthalmology.com/article/unraveling-the-difficult-diagnosis-of-dacryoadenitis 
  10. Taylor RS, Ashurst JV. Dacryocystitis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Nov 2]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK470565/
  11. Aburn NS, Sullivan TJ. Infectious mononucleosis presenting with dacryoadenitis. Ophthalmology. 1996 May;103(5):776–8.
  12. Mombaerts I, Cameron JD, Chanlalit W, Garrity JA. Surgical debulking for idiopathic dacryoadenitis: a diagnosis and a cure. Ophthalmology. 2014 Feb;121(2):603–9.
  13. Rose GE. A personal view: probability in medicine, levels of (Un)certainty, and the diagnosis of orbital disease (With particular reference to orbital ‘pseudotumor’). Arch Ophthalmol. 2007 Dec;125(12):1711–2.
  14. Luemsamran P, Rootman J, White VA, Nassiri N, Heran MKS. The role of biopsy in lacrimal gland inflammation: A clinicopathologic study. Orbit. 2017 Dec;36(6):411–8.

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Alessia Zappa

Integrated Masters, Biomedical Sciences, University of York

Alessia (bilingual in both English and Italian) has recently graduated from the University of York with a Master of Biomedical Science in Biomedical Sciences. Throughout her degree, she has had significant practice in a variety of written communication styles – from literature reviews, grant proposals, laboratory reports, to developing a series of science revision activities aimed for 12-13 year olds. She also has had extensive experience in collecting data, both within a laboratory setting (particularly in cell culture experiments) and online through survey-based projects. She has a particular passion for cancer research and immunology, with her final year project focusing on how the immune cell macrophage can be manipulated in order to target melanoma.

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