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Describe the disorders of the lacrimal gland.

Ophthalmology · 3rd Professional

Anatomy and Assessment

The lacrimal gland lies in the lacrimal fossa of the superotemporal orbit and is divided by the lateral horn of the levator aponeurosis into a larger orbital lobe and a smaller palpebral lobe, the latter visible in the superotemporal fornix on lid eversion
Its ducts (12) pass through the palpebral lobe to open into the superior fornix — which has a surgical consequence: biopsy or excision of the palpebral lobe damages the ducts and renders the whole gland non-functional, so biopsy is taken from the orbital lobe
Nerve supply — parasympathetic secretomotor fibres from the superior salivatory nucleus via the nervus intermedius, greater petrosal nerve and pterygopalatine ganglion, reaching the gland through the zygomatic and lacrimal nerves; sympathetic fibres from the superior cervical ganglion; and sensory supply by the lacrimal nerve

The Disorders

Condition	Features
Acute dacryoadenitis	Painful swelling of the outer third of the upper lid with the classical S-shaped lid deformity, chemosis and tenderness. viral (mumps, Epstein-Barr, influenza) in children, or bacterial. Self-limiting; treated with analgesia, warm compresses and antibiotics if bacterial
Chronic dacryoadenitis	Painless enlargement; consider sarcoidosis, tuberculosis, IgG4-related disease, granulomatosis with polyangiitis, Sjogren syndrome and lymphoma. Requires systemic work-up
Mikulicz syndrome	Bilateral, painless enlargement of the lacrimal and salivary glands; a descriptive term with an underlying cause — sarcoidosis, tuberculosis, lymphoma, leukaemia or IgG4-related disease — which must be sought
Pleomorphic adenoma (benign mixed tumour)	The commonest epithelial tumour of the gland. A painless, slowly growing (over more than a year), firm mass with smooth bony fossa expansion. Critically: it must be excised intact within its pseudocapsule, and incisional biopsy IS contraindicated because it causes seeding, recurrence and eventual malignant transformation
Adenoid cystic carcinoma	The commonest malignant epithelial tumour and the most feared. Rapid growth over months with pain and numbness from perineural invasion, and bony destruction on CT. Requires biopsy, then radical surgery with radiotherapy; the prognosis is poor and late recurrence is characteristic
Lymphoma and lymphoid hyperplasia	A painless, salmon-pink, soft mass that moulds to the globe without bony change; the commonest lacrimal fossa lesion overall in some series. Diagnosed by biopsy, and requires systemic staging
Dacryops	A simple ductal cyst of the palpebral lobe; benign

The decision that matters IS whether TO biopsy, and it turns on the history: a painless mass growing over more than A year with smooth bony expansion is a pleomorphic adenoma and must be excised intact without prior biopsy; a painful mass growing over months with bony destruction is malignant or inflammatory and must be biopsied
Getting this the wrong way round is the classic and irreversible error of lacrimal gland surgery
Biopsy the orbital lobe, not the palpebral lobe, to preserve the ducts and gland function

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