treatment plan

The Partially Swollen Lid

BY WILLIAM L. MILLER, OD, PHD, FAAO

Eyelid swelling is a nonspecific sign and symptom with several causative factors. However, when the upper lid is swollen preferentially affecting the lateral aspect, consider dacryoadenitis as the cause. The appearance of the swelling has been characterized as an S-shaped deformity affecting up to a half of the upper lid.

Causes and Diagnosis

Dacryoadenitis is acute or chronic. The latter is often accompanied with mild to little pain and must be followed to rule out systemic causes for inflammation.

Causes for a bilateral, inflamed, mildly painful dacryoadenitis may include sarcoidosis, tuberculosis, Mikulicz's syndrome (benign lymphoepithelial disease), Graves' ophthalmopathy, and Wegener's granulomatosis. Dacryoadenitis may also occur with Crohn's disease (Dutt et al, 1992). Infectious diseases associated with dacryoadenitis include brucellosis and Lyme disease.

Prompt referral to an internist for chronic and severely acute cases of dacryoadenitis is required to confirm and manage the condition. Consider several laboratory tests to confirm the diagnosis. Without substantive systemic disease factors, a percutaneous needle aspiration biopsy will most likely be performed to exclude neoplastic disease. Presence of blood in the tear film heightens the suspicion of a lacrimal gland neoplasm. In equivocal aspiration biopsies, an incisional biopsy may ultimately be undertaken.

Cases of acute dacryoadenitis may also result from systemic diseases or may indicate a flare up of the condition. Your patient will have obvious upper lid swelling as in the chronic case, however acute cases will demonstrate more severe pain. The eyelid will exhibit erythema, and the palpebral portion of the lacrimal gland may be obviously present on examination of the palpebral conjunctiva. Your patient may be febrile with conjunctival injection and chemosis along with a possible involvement of the submandibular or preauricular lymph nodes and/or parotid gland.

Address infectious causes in patients presenting with an acute dacryoadenitis. These would include bacterial, fungal, and viral vectors, as well as trauma.

Bacterial infections most often occur secondary to trauma or adjacent infection. If discharge is obvious, culture to confirm the presence and specific type of bacteria. Commonly found bacteria include staphylococci and streptococci, but other rarer species have also been identified such as moraxella and hemophilus.

Viruses are another infectious cause and include Epstein-Barr and Herpes Zoster. Therefore viral serologies can be used to confirm your diagnosis. Mumps represents a less frequent cause due to the availability of immunizations in developed countries.

Imaging in cases of acute dacryoadenitis may be helpful in addressing the extent of the lacrimal gland involvement and its affect on surrounding tissue. This can be accomplished with ultrasound or a CT scan of the orbital space using contrast.

Treatment

Treatment in cases of inflammatory dacryoadenitis secondary to a systemic condition is related to the specific disease. In some cases a short course of oral steroids may be indicated. Dacryoadenitis from Epstein-Barr may also respond to oral steroids. Other viral associated cases of dacryoadenitis can be managed with palliative treatment including cold compresses, oral analgesic, and antipyretic medications.

Mild cases of bacterial dacryoadenitis are best handled with oral antibiotics while intravenous antibiotics are reserved for more severe cases. Antibiotics of choice in mild cases in adult patients include cephalexin 500 mg four times a day or amoxicillin 250mg or 50mg three times a day; both for seven days. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #179.

---

Dr. Miller is an associate professor and chair of the Clinical Sciences Department at the University of Houston College of Optometry. He is a member of the American Optometric Association and serves on its Journal Review Board. You can reach him at wmiller@uh.edu.