26.1 Introduction and Anatomy

The lacrimal gland is positioned within the lacrimal fossa of the frontal bone and secured in place with suspensory ligaments in addition to lateral extensions of Whitnall’s ligament. These suspensory ligaments also anatomically separate the lacrimal gland into orbital and palpebral lobes. The orbital lobe has excretory ducts that pass through and join with the ducts of the palpebral lobe, which lies more proximal to the eye. In a normal position, the palpebral lobe can often be seen through the conjunctiva of the superotemporal fornix when the eyelid is everted. Similar to other structures in the body that fall victim to gravity during the aging process, the suspensory ligaments of the lacrimal gland can become lax, resulting in lacrimal gland prolapse (LGP).

Disorders that affect eyelid and periorbital laxity such as sleep apnea and floppy eyelid syndrome, mechanical manipulation, and recurrent periocular edema often due to allergies can predispose patients to LGP. LGP can also be seen in congenital disorders with weak periorbital tissues as seen in congenital ptosis and craniosynostosis. ¹

Often, LGP is found with other involutional changes of the eyelid, such as blepharoptosis in older patients or blepharochalasis in younger patients. Management of the LGP can be combined with a blepharoplasty or ptosis repair. Clinically identifiable LGP was initially reported in about 15% of patients who presented for blepharoplasty evaluation. However, studies of older patient populations, with a mean age of 78, have shown LGP in 60% of cases when examined surgically. ²

LGP often presents as a periocular mass or bulging of the soft tissue (Fig. 26.1 , Fig. 26.2). The palpebral lobe can be seen through the conjunctiva with eyelid eversion, while the orbital lobe presents as soft tissue fullness in the superotemporal eyelid. The prolapsed lacrimal gland can be differentiated from herniated fat by the former being firmer in texture with palpation.

26.2 Goals of Intervention

• 
  

  Repositioning of the lacrimal gland into proper position in the lacrimal gland fossa.

  
  
• 
  

  Improving cosmesis by correcting LGP and minimizing scarring with a superior eyelid crease incision.

  
  
• 
  

  Recovering superior visual field by reversing mechanical ptosis from LGP.

26.3 Risks

• 
  

  Bleeding/hematoma.

  
  
• 
  

  Injury to lacrimal gland resulting in decreased tear production and dry eyes.

  
  
• 
  

  Recurrence of LGP and need for additional surgery.