Lacrimal Disorders

Lacrimal Disorders


Andrew Mick

ICD-9: 375.00



Dacryoadenitis is a disease characterized by inflammation and enlargement of the lacrimal gland and surrounding tissues. Depending on the clinical characteristics and etiology, it is classified as acute, chronic, or granulomatous.


Underlying causes of dacryoadenitis include infectious diseases, inflammatory disorders, malignancies, and benign enlargements.

Acute Dacryoadenitis

Andrew Mick

ICD-9: 375.01


The Patient

Clinical Symptoms

  • Sudden onset of pain in the superior temporal orbit

  • Upper temporal eyelid is swollen, red, and tender to touch (Fig. 11-1)

  • Secondary conjunctival injection and symptoms of eye irritation and tearing

  • Double vision in attempted superior gaze in severe cases

Clinical Signs

  • Unilateral more commonly than bilateral

  • Lacrimal gland enlarged and inflamed

  • Palpebral, orbital, or both lobes of the lacrimal gland may be involved

  • Chemosis of surrounding conjunctiva with an occasional follicular response

  • “S-shaped ptosis” due to relative involvement of upper temporal eyelid

  • Mucopurulent discharge may be present in bacterial etiologies

  • Tender palpable ipsilateral preauricular nodes more common with viral etiologies

  • Proptosis, downward displacement of the globe, or mild extraocular muscle (EOM) disruption in severe cases


Acute dacryoadenitis is a rare disorder usually of infectious etiology. It is most common in children and young adults, but individuals of all ages can be affected. Route of infection can be blood borne, transconjunctival, transneuronal, or
through direct inoculation from trauma. Common causative agents are viruses including mumps, Epstein-Barr (mononucleosis), herpes simplex, herpes zoster, and rarely human immunodeficiency virus (HIV). Bacterial dacryoadenitis is less common and often accompanies traumatic inoculation. Bacterial etiologies include Staphylococcus sp., Streptococcus sp., Haemophilus influenzae, and Neisseria gonorrhoeae. Systemic inflammatory disorders such as sarcoidosis, Wegener’s granulomatosis, and Crohn’s disease usually manifest as chronic or bilateral dacryoadentis but must be ruled out. Rarely neoplastic etiologies including leukemia and lymphoma present as acute dacryoadenitis.

Figure 11-1. Dacryoadenitis.

Significant History

  • Recent and rapid onset of symptoms

  • Occasional fever and leukocytosis

Laboratory Tests

  • Complete blood count (CBC) with differential: Leukemia, lymphoma

  • Culture any discharge on blood (most bacteria), chocolate (Haemophilus sp., Neisseria gonnorrhoeae), and thioglycollate agar (aerobic and anaerobic bacteria)

  • Computed tomography (CT), magnetic resonance imaging (MRI), or orbital ultrasound: Delineates extent of tissue involvement, especially indicated with proptosis, downward displacement of the globe, limited EOM motility, or decreased vision

  • Blood titers for appropriate suspected viral etiologies: Mumps, Epstein-Barr, HIV

  • Lacrimal gland biopsy: Atypical presentations or lack of appropriate treatment response

The Treatment

Broad-spectrum antibiotics should be initiated until cultures, titers, and laboratories can better direct therapy. Appropriate choices would include

  • Amoxicillin/clavulanate 500/125 mg twice daily

  • Cephalexin 250 to 500 mg four times daily

  • Penicillin/cephalosporin sensitive: Azithromycin: 500 mg daily for 3 days or 250 mg twice a day for 1 day, then once daily for 4 days

  • Severe presentations or pediatric cases: Referral for possible hospitalization with intravenous (IV) drug therapy

Viral Etiologies

  • Cool compresses

  • Topical lubricants

  • Appropriate analgesic as needed

  • Suspected herpetic: Acyclovir 400 mg five times a day (simplex) or 800 mg five times a day (zoster), Valacyclovir 1,000 mg three times a day, Famciclovir 500 mg three times a day

Chronic/Granulomatous Dacryoadenitis

Andrew Mick

ICD-9: 375.02


The Patient

Clinical Symptoms

  • Chronic or recurrent swelling and redness of the upper lid

  • Bilateral cases more common than with acute dacryoadenitis

  • Occasional pain and double vision

Clinical Signs

  • Localized mass in the lateral upper eyelid area

  • Lacrimal gland enlarged and inflamed

  • Proptosis, downward displacement of the globe, or EOM disruption in severe cases


Chronic/granulomatous dacryoadenitits has a variety of etiologies: Inflammatory (sarcoidosis, Wegener’s granulomatosis, Crohn’s disease), infectious (tuberculosis, mumps, HIV, syphilis), and neoplastic (leukemia, lymphoma)

Significant History

  • Symptoms/signs of systemic infectious, inflammatory, or neoplastic disease

Laboratory Tests

  • Suspected leukemia/lymphoma: CBC with differential

  • Suspected sarcoidosis: Chest x-ray, serum angiotensin-converting enzyme (ACE)

  • Suspected Wegener’s granulomatosis: Sinus/chest x-ray, antineutrophil cytoplasmic antibody (ANCA) test, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)

  • Suspected Crohn’s disease: History of characteristic symptoms (weight loss, chronic diarrhea, abdominal pain), hematocrit/hemoglobin (gastrointestinal bleeding), ESR, x-ray with barium, abdominal CT

  • Suspected tuberculosis: Purified protein derivative with anergy panel

  • Suspected syphilis: Rapid plasma reagin or Venereal Disease Research Laboratory and fluorescent treponemal antibody absorption

  • Suspected HIV: Serology

  • CT, MRI, or orbital ultrasound: Delineates extent of tissue involvement, especiallyindicated with proptosis, downward displacement of the globe, limited EOM motility, or decreased vision.

  • Lacrimal gland biopsy

The Treatment

  • Treatment will depend on the underlying cause of the chronic dacryoadenitis and will involve referral to appropriate subspecialist for evaluation.


Andrew Mick

ICD-9: 375.30



The disorder is characterized by acute or chronic infection or inflammation of the lacrimal sac. Complete or partial obstruction of the nasolacrimal duct is often the precipitating event prior to infection. Obstruction can result from developmental anomalies, nasal/sinus disease, trauma, neoplasm, dacryolith formation (lacrimal calculi), or systemic inflammatory disease.


Acute (ICD-9: 375.32)

  • Lacrimal stenosis that results in secondary acute and severe infection

  • Commonly cultured bacteria are Gram positive (Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae) and Gram negative (Pseudomonas aeruginosa, Escherichia coli)

  • Rarely anaerobicbacteria (Actinomyces israelii, Propionibacterium acnes)

  • Rarely fungi (Aspergillus sp., Candida sp.)

Chronic (ICD-9: 375.42)

  • Partial or complete blockage of the nasolacrimal system that results in secondary chronic infection

  • Commonly cultured pathogens include Gram-positive bacteria (Staphylococcus sp., Streptococcus sp.), coagulase-negative staphylococci, Gram-negative bacteria (P. aeruginosa, E. coli), and fungi (Aspergillus sp., Candida sp.)

The Patient

Clinical Symptoms


  • Pain, redness, and swelling around the lacrimal sac

  • Tearing and discharge

  • Occasional fever


  • Tearing may be the only symptom in many cases

  • Occasional swelling around the lacrimal sac

  • Discomfort with local digital pressure

Clinical Signs


  • Edema and hyperemia around the lacrimal sac

  • Swelling concentrated under the medial canthal ligament

  • Mucopurulent discharge expressed from the puncta

  • Localized abscess with possible breakthrough to the skin surface (Fig. 11-2)

  • Occasional preauricular and submandibular swollen lymph nodes


  • Epiphora

  • Local swelling around lacrimal sac

  • Mucopurulent material expressed from puncta with digital pressure


Acute dacryocystitis occurs in all age groups with highest incidence in middle-aged adults. Women are afflicted more commonly than men and whites more commonly than other races. Chronic dacryocystitis can occur in infancy with congenital nasolacrimal obstruction. More commonly, it presents in elderly patients often due to involutional stenosis or scarring of the nasolacrimal drainage system.

Figure 11-2. Dacryocystitis.

Significant History

  • Tearing

  • Discharge

  • Chronic conjunctivitis

  • Chronic sinusitis or current upper respiratory tract infection

Laboratory Tests

  • Culture-expressed discharge on blood (all bacteria), chocolate (children: Haemophilus sp.), thioglycollate (aerobic and anaerobic), Sabouraud’s (fungal) agar

  • CT scan of orbit and sinuses to rule out widespread pathology or neoplasm: When no immediate improvement occurs with appropriate therapy

The Treatment

Broad-spectrum antibiotics that have coverage for the common bacterial causative agents should be initiated until cultures can better direct therapy. Appropriate choices would include

  • Amoxicillin/clavulanate 500/125 mg twice a day

  • Cephalexin 250 to 500 mg four times a day

  • If penicillin/cephalosporin sensitive: Azithromycin 500 mg daily for 3 days or 250 mg twice a day for 1 day, then once daily for 4 days

  • Severe presentations or pediatric cases: Referral for possible hospitalization with IV drug therapy

  • Warm compresses

  • Analgesic therapy is important because there is often significant pain. Appropriate therapy includes:

    • Mild pain: Acetaminophen 500 mg every 4 to 6 hours, Ibuprofen 400 to 600 mg every 4 to 6 hours, Naproxen 250 to 500 mg two times a day

    • Moderate pain: Acetaminophen with codeine (30 mg codeine) every 4 to 6 hours

    • Severe pain: Acetaminophen (500 mg) with hydrocodone (5 mg) every 4 to 6 hours, Ibuprofen (200 mg) with hydrocodone (7.5 mg) every 4 to 6 hours, Acetaminophen (325 mg) with oxycodone (10 mg) every 4 to 6 hours

  • Consider incision for nonresolving dacryocystitis with abscess

  • Consider external or endonasal endoscopic dacryocystorhinostomy (DCR) for nonresolving dacryocystitis

  • Febrile or pediatric cases with systemic disease should be referred for possible hospitalization with IV drug therapy


Andrew Mick





The disorder is characterized by infection or inflammation of the canaliculi.


Infectious agents include bacteria (A. israelii, Propionibacterium propionicum), fungi (Candida sp., Aspergillus sp.), and viruses (Herpes simplex). Canaliculitis is rarely associated with intracanalicular punctal plug occlusion.

The Patient

Clinical Symptoms

  • Irritation, redness, and swelling over medial portion of eyelids

  • Tearing and discharge

Clinical Signs

  • Mucopurulent discharge or concretions expressed from punctum

  • Concretions felt while probing canaliculus

  • Conjunctivitis more severe nasally

  • Erythematous area around punctal openings

  • Periocular skin vesicles (herpes simplex)


Canaliculitis can affect people of all ages but is more common in elderly populations.

Significant History

  • Chronic/recurrent conjunctivitis

  • Epiphora

  • History of herpetic eye disease

Laboratory Tests

  • Culture any discharge from punctum on blood (all bacteria), chocolate (children: Haemophilus sp.), thioglycollate (aerobic and anaerobic bacteria), and Sabouraud’s (fungi) agar

The Treatment

  • Cultures positive for bacteria: Polymyxin B/trimethoprim solution four times a day or as directed by cultures

  • Cultures positive for fungus: Natamycin 5% suspension four times a day

  • Suspected herpetic infection: Trifluridine 1% solution four times a day

  • Removal of debris in canaliculus with irrigation

  • Canaliculotomy or snip punctoplasty may be indicated in nonresponsive canaliculitis


Andrew Mick

ICD-9: 375.20



The presentation of excessive tearing can be because of lacrimal hypersecretion or failure of the lacrimal system
to adequately drain the tears. The four primary mechanisms are as follows:

  • Dry eye or other secondary causes of reflex hypersecretion of tears

  • Blockage within the lacrimal drainage apparatus or punctal malposition

  • Secondary hypersecretion of the lacrimal gland due to mechanical effects

  • Primary hypersecretion of the lacrimal gland


  • Dry eye: Dryness produces ocular irritation that results in subsequent hypersecretion of tears

  • Secondary hypersecretion: Environmental irritants (smog, dust, or pollen) and mechanical irritants (trichiasis, entropion, or ectropion) can also produce irritation and induce hypersecretion

  • Primary hypersecretion: Many etiologies can produce direct stimulation of the lacrimal gland by infection/inflammation (see “Dacryoadenitis”): Viral infections (mumps, Epstein-Barr, herpes zoster), bacterial infections (Straphylococcus sp., Streptococcus sp., N. gonorrhoeae) inflammatory conditions (sarcoidosis, thyroid ophthalmopathy, Wegener’s granulomatosis, Sjögren’s syndrome)

  • Use of topical or systemic parasympathomimetic agents

  • Tumors of the lacrimal gland

Blockage of the Lacrimal Drainage System

Blockage of lacrimal drainage can be congenital or acquired and occur proximally or distally within the system.

Congenital Structural Blockage

ICD-9: 375.55 OR 743.65

The most common congenital causes of nasolacrimal obstruction include the following:

  • Failure of the distal end of the duct to completely canalize during development

  • Lack/malformation/membranes of one or more puncta

  • Lack/malformation/membranes of the canaliculi

  • Congenital tumors of the lacrimal sac:

    • Mucocele

    • Hemangioma

    • Dermoid

  • Membrane/cyst in the nasolacrimal duct

Acquired Structural Blockage

ICD-9: 375.56

Acquired nasolacrimal duct obstruction in adults is most often caused by age-related anatomical changes or low-grade infection or inflammation of the lacrimal drainage system. Proximal end blockage:

  • Lid ectropion resulting in eversion of the punctum away from the tear lake: Ectropion can be caused by any chronic inflammation/infection (blepharitis, allergic conjunctivitis), scarring (chemical burns, skin disease), facial nerve palsy, age-related changes to the lid anatomy, or history of blepharoplasty

  • Megalocaruncles: Enlarged caruncle that extends to the level of the lower punctum with excess tissue that pushes punctum away from its appositional location with the tear lake

  • Punctal stenosis: Scarring/narrowing/occlusion

  • Canalicular stenosis: Scarring/narrowing/occlusion, topical and systemic medications can cause scarring (topical timolol, systemic docetaxel, systemic 5-fluorouracil)

Distal end blockage:

  • Lacrimal sac and nasolacrimal duct obstructions: Dacryocystitis, dacryolith formation, cysts, mucocele, neoplasms

The Patient

Clinical Symptoms

  • Watering of one or both eyes, with or without periocular pain

  • Pain, redness, and swelling around lacrimal sac or upper lid

  • Foreign body sensation

Clinical Signs

  • Negative Jones I or II tests

  • Asymmetric dye disappearance test

  • Increased lacrimal tear lake

  • Lid, punctum, caruncle abnormalities

  • Tender swollen lacrimal gland or sac area

  • Expression of purulent material from the punctum


Epiphora can present in all age groups.

Significant History

  • Persistent tearing

  • Recurrent sinusitis or dacryocystitis

  • Swelling or pain over lacrimal sac

  • History of facial trauma or lid surgery

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Jul 21, 2016 | Posted by in OPHTHALMOLOGY | Comments Off on Lacrimal Disorders
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