Lacrimal Gland Disorders

What the lacrimal gland does

The main lacrimal gland sits in a shallow hollow of the frontal bone, above and to the outside of each eye. It has two parts, one deep in the eye socket (orbital lobe) and one under the eyelid (palpebral lobe), which you can sometimes see when you pull the upper lid up and look down and in. Small ducts release watery tears onto the eye surface. These tears are drained at the inner corner, through the tear duct into the nose.

Problems can affect tear production (too little) or the gland itself (swelling, inflammation, growths). Problems with drainage, such as an infected tear sac (dacryocystitis), are different conditions at the opposite corner of the eye.

Types of lacrimal gland disorders

Acute dacryoadenitis

Sudden inflammation, usually from infection. It causes:

• pain, redness and swelling of the outer third of the upper eyelid
• an S-shaped droop of the lid edge
• tenderness, and sometimes swollen lymph nodes in front of the ear
• watering or discharge, and sometimes fever

In children and young adults it is often viral: Epstein-Barr virus (glandular fever), mumps, adenovirus or herpes viruses. Bacterial infection, usually Staphylococcus or Streptococcus, can form an abscess.

Chronic dacryoadenitis and enlargement

Slower, often painless swelling lasting weeks to months. Causes include:

• sarcoidosis, often in both glands, sometimes with salivary gland swelling
• thyroid eye disease
• IgG4-related disease and idiopathic orbital inflammation
• Sjogren's syndrome
• granulomatosis with polyangiitis and, rarely, tuberculosis

Reduced tear production

When the gland makes too few tears, the result is aqueous-deficient dry eye. Causes:

• Sjogren's syndrome, an autoimmune disease that attacks tear and saliva glands
• aging and menopause
• radiation therapy, graft-versus-host disease after bone marrow transplant
• medicines with anticholinergic effects (antihistamines, some antidepressants)
• damage to the nerve that stimulates tearing

Cysts and tumors

About half of lacrimal gland masses are inflammatory and half are tumors.

• Dacryops: a fluid-filled duct cyst, usually harmless.
• Lymphoma: the most common lacrimal gland malignancy in older adults; it typically presents as a painless, rubbery swelling.
• Pleomorphic adenoma: a benign epithelial tumor, slow-growing over a year or more. It must be removed whole because it can recur or turn malignant if cut into.
• Adenoid cystic carcinoma: a rare cancer, often painful because it invades nerves, and may cause numbness.

Symptoms that point to the cause

How lacrimal gland disorders are diagnosed

• Eye examination: lifting the upper lid to see the palpebral lobe, checking eye movement, vision and eye position.
• Tear tests: a Schirmer strip measures tear production over 5 minutes; dye tests check the tear film.
• Blood tests: markers of infection and inflammation, thyroid tests, ACE and calcium for sarcoidosis, Sjogren's antibodies (SSA/Ro, SSB/La), IgG4 levels.
• Imaging: CT or MRI of the orbit shows whether the gland is diffusely swollen (inflammation) or contains a defined mass, and whether bone is involved.
• Biopsy: needed for persistent swellings without a clear cause, to rule out lymphoma or other tumors. For a suspected pleomorphic adenoma, the whole gland lobe is removed instead.

Treatment

• Viral dacryoadenitis: warm compresses and pain relief; it usually settles in 1 to 2 weeks.
• Bacterial dacryoadenitis: oral antibiotics, or IV antibiotics in hospital if severe; an abscess may need draining.
• Chronic inflammation: steroids or other immune-suppressing medicines, guided by the underlying disease.
• Dry eye from low tear production: artificial tears and gels, punctal plugs to slow drainage, prescription anti-inflammatory drops, and treatment of Sjogren's.
• Lymphoma: radiotherapy or chemotherapy, depending on type and spread.
• Benign tumors: complete surgical removal.
• Malignant epithelial tumors: surgery, often with radiotherapy, at a specialist orbital center.

Outlook

Infectious dacryoadenitis usually clears completely. Chronic inflammatory causes often respond to treatment but can recur. Benign tumors are cured when removed intact. Lacrimal gland cancers are rare and more serious, and need long-term follow-up.

Frequently asked questions

What is dacryoadenitis?

Dacryoadenitis is inflammation of the tear gland. Acute cases cause a painful, red, swollen outer upper eyelid, often from a virus such as the one behind glandular fever or mumps. Chronic cases are usually painless and linked to diseases like sarcoidosis or thyroid eye disease.

What does a swollen lacrimal gland look like?

The outer part of the upper eyelid looks full or puffy, and the lid edge may droop in an S shape. Lifting the lid can reveal a pink swollen lobe. A tender, red swelling suggests infection; a painless, firm one needs tests to rule out a tumor.

How is a tear gland infection treated?

Viral tear gland infections usually settle with warm compresses and pain relief within 1 to 2 weeks. Bacterial infections need antibiotics, and severe cases may need hospital treatment or drainage of an abscess. Any fever with spreading swelling needs prompt medical care.

Can lacrimal gland problems cause dry eyes?

Yes. When the gland does not make enough watery tears, the eye becomes dry, gritty and sore. Sjogren's syndrome, aging, radiation and some medicines are common causes. Artificial tears and treating the underlying condition help.

What is the difference between dacryoadenitis and dacryocystitis?

Dacryoadenitis affects the tear gland at the outer upper eyelid. Dacryocystitis is infection of the tear sac at the inner corner beside the nose, from a blocked tear duct. They have different causes and treatments.