Download Grand Rounds - University of Louisville Ophthalmology

Grand Rounds Conference
Eric Downing MD
University of Louisville
Department of Ophthalmology and Visual Sciences
Subjective
CC/HPI: 31F presents with right eye pain, upper
lid edema/tenderness and copious discharge
OD x 2 days. She has mild/moderate pain with
EOM, but no diplopia. She denies any vision
changes, fever, or congestion.
History
POH: none
PMH: none
Eye Meds: none
Meds/Allergies: none, NKDA
Social Hx: no pets, no travel
Objective
VA:
Pupils:
IOP:
EOM:
OD
20/25
5->2
21
full OU
OS
20/20
5->2, no rAPD
18
Objective
PLE:
E/L/L:
C/S
K
AC
I/L
Vit
DFE: all WNL OU
OD
ST erythema/edema
1+ injection, mild temporal chemosis
Clear
D&Q
WNL
WNL
Clinical photos
Clinical photos
Assessment



31F with moderate/severe unilateral
superotemporal orbital pain x 2 days with
copious watery discharge.
CT scan showing inflammation/hyperintensity
of the right lacrimal gland
Dx: Acute Dacryoadenitis
Laboratory

CBC:
14.1
12.8
318
43.0



BMP: WNL
ESR/CRP: 7/9.4
EBV: IgG positive, IgM positive
Laboratory

CBC:
14.1
12.8
318
43.0
9



BMP: WNL
ESR/CRP: 7/9.4
EBV: IgG positive, IgM positive
Treatment



One dose IV Vanc and Ceftriaxone in ED
Sent home on po Keflex x 5 days
Warm compresses PRN
Background





Self-limited condition
Inflammatory enlargement
of the lacrimal gland
Pathophysiology poorly
understood but thought to
be due to ascension from
the conjunctiva
1/10K ophtho patients
Acute & Chronic forms
Forms of Dacryoadenitis

Acute
Unilateral severe pain, redness, and pressure in ST
quadrant
 Rapid onset


Chronic
Unilateral or bilateral
 Painless enlargement of lacrimal gland > 1 month
 More common

Etiology

Infectious



Viral: Mumps, Epstein-Barr Virus, HZV, Mononucleosis
Bacterial: Staph aureus, N. gonorrhoeae, Syphilis,
Chlamydia, TB
Inflammatory

Sarcoidosis, Grave’s Dz, Sjögren’s, IgG-4 related disease,
benign lymphoproliferative lesions
Exam







Gland is often prolapsed,
enlarged, and tender
Chemosis
Injection
Mucopurulent discharge
Eyelid edema/erythema
Submandibular adenopathy
Mild ophthalmoplegia
Treatment




Viral: supportive measures (e.g. warm
compresses, oral NSAIDs)
Bacterial: oral Cephalosporin such as Keflex
Inflammatory: treat underlying disease
Consider biopsy if refractory to treatment of
underlying disease
Research





Retrospective case series
8 patients with IgG-4 related disease of salivary and
lacrimal glands
Performed EBV FISH analysis on biopsied tissues
Found a positive correlation
between IgG-4 concentrations
and EBV load
EBV viral load may have
prognostic value in these pts
References
1.
2.
3.
4.
Kanski JJ. Acute dacryoadenitis. Clinical Ophthalmology: A Systemic
Approach 6th edition. Butterworth, Heineman, Elsevier; 2014: 178-179.
BCSC 7 Orbit, Eyelids, and Lacrimal System:2014. pp 273-274
Rhem MN, Wilhelmus KR, Jones DB. Epstein-barr virus dacryoadenitis. AM
J Ophthlmol 2000;129:372-5
Boruchoff SA, Boruchoff SE. Infections of the lacrimal system. Infect Dis
Clin North Am. Dec 1992;6(4):925-32.