Dacryoadenitis, other diseases of the lacrimal gland, epiphora

Dry Eye Syndrome: By etiology: • syndromic "dry eye";

• symptomatic "dry eye", which accompanies: • certain types of ocular pathology and operations on the visual organ; • individual hormonal disorders; • a number of somatic diseases; • local and enteral administration of certain medications; • vitamin A deficiency. • artifactual.

By pathogenesis: • reduction in the volume of basic tear production; • destabilization of the tear film under the influence of exogenous factors or increased evaporation; • combined effect of the above-mentioned factors.

By clinical picture: • recurrent microerosion of the cornea or conjunctiva of the eyeball; • recurrent macroerosion of the cornea or conjunctiva of the eyeball; • "dry" keratoconjunctivitis; • "filamentary" keratitis.

By severity: • mild (with microsigns of xerosis against the background of reflex hyperlacrimation, while the tear film break-up time is 8.0±1.0 s); • moderate (with microsigns of xerosis, but already against the background of moderate reduction in tear production and stability of the precorneal tear film); • severe and particularly severe (with macrosigns of xerosis against the background of pronounced or critical reduction in tear production and stability of the precorneal tear film).

CLINICAL PROTOCOL FOR DIAGNOSIS AND TREATMENT

correlational studies and clinical case studies.

V

Evidence is based on clinical cases and examples.

A High-quality meta-analysis, systematic review of RCTs or large RCT with very low probability (++) of systematic bias, the results of which can be generalized to the relevant population.

B High-quality (++) systematic review of cohort or case-control studies or High-quality (++) cohort or case-control studies with very low risk of systematic bias or RCTs with low (+) risk of systematic bias, the results of which can be generalized to the relevant population.

C Cohort or case-control study or controlled study without randomization with low risk of systematic bias (+).

The results of which can be generalized to the relevant population or RCTs with very low or low risk of systematic bias (++ or +), the results of which cannot be directly generalized to the relevant population.

D Case series description or uncontrolled study or expert opinion.

GPP

Best clinical practice.

Clinical classification: Dacryoadenitis: By course:

• acute; • chronic. By etiology: Exogenous: • viruses (epidemic parotitis, infectious mononucleosis, Herpes zoster, cytomegalovirus, influenza, measles, etc.); • bacteria (staphylococcal, streptococcal, pneumococcal, gonococcal, syphilis, Mycobacterium leprae bacilli, Mycobacterium tuberculosis, tick-borne borreliosis, etc.); • fungi; • parasites. Endogenous: • infectious (syphilis, Mycobacterium leprae bacilli, Mycobacterium tuberculosis, etc.); • systemic diseases (sarcoidosis, Sjögren's syndrome, Graves' disease, diseases of the blood and lymphatic system); • pseudotumorous nonspecific dacryoadenitis.

Lacrimal gland tumors: • benign (cysts (dacryops), adenoma, etc.); • malignant (carcinoma, cylindroma, etc.).

Atrophy and dystrophy of the lacrimal gland. Anomalies of position and development of the lacrimal gland: • hypoplasia, aplasia of the lacrimal gland; • hypertrophy of the lacrimal gland; • displacement of the lacrimal gland.

Lacrimal gland dysfunction in general diseases: • hormonal (menopause, oral contraceptive use, pregnancy, lactation); • pharmacological suppression of tear production.

Epiphora: • Lack of tear secretion due to pathology of the lacrimal glands or their innervation leads to drying of the tear film and consequently to dry eye syndrome. The same consequences can result from increased evaporation of tear fluid, which usually causes reflex protective increase in tear production.

METHODS, APPROACHES AND DIAGNOSTIC PROCEDURES 2.1 Diagnostic criteria: Complaints: Acute dacryoadenitis: • pain and redness of the skin in the projection of the lacrimal gland; • eyelid skin edema; • drooping of the upper eyelid. Chronic dacryoadenitis: • presence of swelling in the lacrimal gland area; • displacement of the eyeball, • diplopia. DES: • burning sensation in the eye area; • feeling of dry eyes;

• redness of the eyes; • foreign body sensation, "sand" in the eye area; • rapid visual fatigue. Epiphora: • tearing, tear stagnation. History: • ante- and postnatal history; • information about concomitant and previously suffered diseases (including allergic history). Physical examination General examination: • edema, hyperemia of the skin in the projection of the lacrimal gland; • drooping of the outer half of the upper eyelid, characteristic S-shaped form of the upper eyelid margin; • displacement of the eyeball downward and inward; • enlargement and palpation tenderness in the projection of the lacrimal gland; • exophthalmos; • narrowing of the palpebral fissure; • conjunctival hyperemia; • tear stagnation; • tearing; • enlargement of regional lymph nodes; • elevated body temperature. Laboratory investigations: bacteriological examination of conjunctival cavity discharge for microflora with determination of antibiotic sensitivity, histopathological examination to exclude (or confirm) oncological process.

Instrumental investigations: • visometry: possible reduction in visual acuity, presence of diplopia; • biomicroscopy: conjunctival/mixed injection, in the upper outer angle when everting the upper eyelid protrusion of the enlarged palpebral part of the gland, xerosis of the corneal and conjunctival surface; • ophthalmoscopy: possible changes characteristic of the underlying pathology; • tonometry: elevated intraocular pressure; • Schirmer test – test strip wetting level less than 15mm; • ultrasound (B-scan) of eyes, adnexal apparatus, orbit: determination of size and position of the orbital part of the lacrimal gland; • CT/MRI with or without contrast agent of orbits: visualization of the orbit, in vivo non-invasive examination of the lacrimal gland, increases diagnostic accuracy of the disease, exclusion or confirmation of oncological process;

• lacrimal passage irrigation: impaired patency of lacrimal passages; • determination of Ig G4. Indications for specialist consultations: • otorhinolaryngologist consultation when ENT organ pathology is detected; • dentist consultation when dental and oral cavity pathology is detected; • oncologist consultation when oncological pathology is suspected; • neurologist consultation when nervous system pathology is detected; • infectious disease specialist consultation when infectious diseases are detected; • endocrinologist consultation in the presence of concomitant endocrine pathology; • rheumatologist consultation in the presence of autoimmune pathology

Clinical diagnosis

ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION: 6.1 List of protocol developers with qualification details: 1) Dzhumataev Erik Asylkhanovich – Candidate of Medical Sciences, Head of Paid Day Hospital at LLP "Kazakh Research Institute of Eye Diseases", physician of the highest category; 2) Aubakirova Alua Sauytbekovna – Candidate of Medical Sciences, physician of the highest category, LLP "Kazakh Research Institute of Eye Diseases"; 3) Sultankulova Banu Tastemirovna – ophthalmologist of the 1st category, LLP "Kazakh Research Institute of Eye Diseases"; 4) Zhanataev Zhasulan Bazarkhanovich – ophthalmologist at LLP "Kazakh Research Institute of Eye Diseases"; 5) Eralieva Bibikhan Abdalieva – Doctor of Medical Sciences, Head of the Department of Clinical Pharmacology at JSC "Kazakh Medical University of Continuing Education". 6.2 Conflict of interest: none. 6.3 Reviewer: Utelbayeva Zauresh Tursunovna – Doctor of Medical Sciences, Professor of the Department of Ophthalmology at JSC "National Medical University". 6.4 Indication of conditions for protocol revision: revision of the protocol 5 years after its publication and from the date of its entry into force or in the presence of new methods with evidence level. 6.5 List of references used:

Approved by the Joint Commission on Quality of Medical Services of the Ministry of Health

of the Republic of Kazakhstan dated November 19, 2019

Protocol No. 77

DACRYOADENITIS, OTHER DISEASES OF THE LACRIMAL GLAND, EPIPHORA

INTRODUCTORY PART

ICD-10 Code(s):

Code Name H04.0 Dacryoadenitis H04.1 Other diseases of lacrimal gland H04.2 Epiphora

Date of protocol development/revision: 2015 (revised 2019).

Abbreviations used in the protocol:

STD – sexually transmitted diseases CT – computed tomography MRI – magnetic resonance imaging NSAIDs – nonsteroidal anti-inflammatory drugs DES – dry eye syndrome US – ultrasound examination ECG – electrocardiography

Protocol users: general practitioners, therapists, pediatricians, surgeons, oncologists, ophthalmologists. 1.5 Patient category: adults, children. 1.6 Evidence level scale:

Evidence level I

II Type of evidence Evidence obtained from meta-analysis of a large number of well-designed randomized studies.

Randomized studies with low levels of false-positive and false-negative errors.

Evidence based on results of at least one well- designed randomized study.

Randomized studies with high levels of false-positive and false-negative errors.

III Evidence based on results of well-designed non-randomized studies. Controlled studies with one patient group, studies with historical control group, etc.

IV Evidence obtained from non-randomized studies. Indirect comparative, descriptive

Diagnostic algorithm:

Complaints

History

Physical examination

Differential diagnosis and justification for additional investigations

Differential diagnosis of acute dacryoadenitis is performed with upper eyelid abscess and orbital phlegmon.

Diagnosis Acute dacryoadenitis

Upper eyelid abscess Justification for differential diagnosis Pain, hyperemia and eyelid edema

Pain, hyperemia and eyelid edema

Investigations Symptoms

Biomicroscopy

Radiography of orbit and paranasal sinuses Lacrimal pathway irrigation Symptoms

Biomicroscopy

Criteria for excluding diagnosis

Pain Redness Swelling in the area of the upper-temporal third of the upper eyelid Edema Pus/discharge conjunctival/mixed injection, in the upper-outer angle when everting the upper eyelid protrusion of the enlarged palpebral part of the gland, xerosis of the corneal and conjunctival surface visualization of the orbit increases diagnostic accuracy, exclusion or confirmation of oncological process impaired patency of lacrimal pathways Bursting pain Headache Sharply pronounced hyperemia and eyelid edema Palpebral fissure is closed Skin is tense, hyperemic, sometimes acquires a yellowish tint. Presence of infiltration or fluctuation in the eyelid area. Elevated body temperature. Vision is not reduced. conjunctival/mixed injection, yellowish-colored

Orbital phlegmon Pain, hyperemia and eyelid edema

Radiography of orbit and paranasal sinuses Lacrimal pathway irrigation Symptoms

Biomicroscopy Radiography of orbit and paranasal sinuses Lacrimal pathway irrigation

pus shows through the skin. An infiltrate is detected in the central or lateral part of the upper eyelid visualization of the orbit increases diagnostic accuracy, exclusion or confirmation of oncological process lacrimal pathways may be patent Pronounced pain syndrome. Rapid development within several hours. Eyelid edema of red-violet color. Exophthalmos, limited mobility of the eyeball. Significant vision reduction up to blindness, diplopia. On the fundus -- congestive optic disc. Headache High temperature, chills. Slowed pulse, possible addition of cerebral symptoms. Pronounced blepharospasm. Conjunctival chemosis up to its incarceration in the palpebral fissure visualization of the orbit increases diagnostic accuracy, exclusion or confirmation of oncological process Lacrimal pathways are patent

Differential diagnosis of DES is performed with acute conjunctivitis Diagnosis Justification for Investigations Criteria for excluding differential diagnosis diagnosis

DES

Hyperemia, itching, Symptoms Discomfort foreign body Burning sensation and dryness in sensation in the the eyes eyes Foreign body sensation in the eyes Mild redness Asthenopia Biomicroscopy Conjunctival hyperemia, reduction or complete absence of tear menisci at the eyelid margins.

Characteristic discharge from the conjunctival cavity.

When treating the eyelids, due to high viscosity, it is drawn out into thin mucous threads Schirmer test Decreased tear production Bacterial Negative culture Acute Hyperemia, itching, Symptoms Discomfort conjunctivitis foreign body Foreign body sensation in the sensation in the eyes eyes Itching Redness Purulent discharge from the eyes Biomicroscopy Hyperemia, looseness of the conjunctiva. Follicle enlargement, formation of exudative films Bacterial Identification of pathogen.

culture Detection of growth of pathological cultures in culture from the conjunctival cavity

Non-pharmacological treatment:

• regimen – III

• diet – table No. 15 or depending on concomitant disease

(arterial hypertension, diabetes mellitus, etc.).

Pharmacological treatment: etiotropic treatment – antibacterial,

anti-inflammatory, tear replacement drugs.

• List of essential medicines (with 100% probability

of use): none.

• List of additional medicines (less than 100%

probability of use):

Pharmacotherapeutic International Route of

Evidence group nonproprietary name administration level Antibacterial drug of Ciprofloxacin Instillations into C the fluoroquinolone Ciprofloxacin conjunctival group 0.3% 5 ml cavity Antibacterial drug of Ceftriaxone Intramuscular C the cephalosporin injection group Rehydrants Carbomer Instillations into C conjunctival cavity Glucocorticoids dexamethasone Parabulbar B

for local injections

application in

ophthalmology Glucocorticoids methylprednisolone intravenously C

for systemic

application immunosuppressant cyclosporine A instillations C

Surgical intervention:

• Occlusion of lacrimal puncta with placement of occluders.

Indications: ineffectiveness of tear replacement, conservative therapy in dry eye syndrome.

Further management:

• within 1 week - antibacterial therapy, from 2 weeks to 1 month after surgery instillation of tear replacement preparations;

• in the presence of concomitant disease monitoring by a specialist;

• scheduled follow-up with an ophthalmologist.
• adherence to appropriate therapeutic and protective regimen as indicated.

3.5 Indicators of treatment effectiveness and safety of diagnostic and treatment methods described in the protocol:

• in inflammatory diseases – resolution of the inflammatory process;
• in dry eye syndrome - elimination of changes associated with xerosis;
• in epiphora absence of excessive lacrimation and tear pooling;
• absence of ocular discomfort.

TREATMENT TACTICS AT INPATIENT LEVEL:

5.1 Patient observation card, patient routing: Ophthalmologist consultation

Ineffectiveness of conservative therapy for dacryoadenitis

Orbitotomy

Non-drug treatment

• regimen – III • diet – table No. 15 or depending on concomitant disease (arterial hypertension, diabetes mellitus, etc.).

Physiotherapy for chronic dacryoadenitis:

• helium-neon laser;
• magnetotherapy.

Drug treatment:

etiotropic treatment – antibacterial, anti-inflammatory, tear replacement preparations.

• List of essential medicines (with 100% probability of use): none

• List of additional medicines (less than 100% probability of use)

Drug group International Manner of Level of

nonproprietary administration evidence

name Antibacterial Ofloxacin Instillations into C

preparation of the conjunctival

fluoroquinolone cavity

group Antibacterial Ceftriaxone Intramuscular C

preparation of the injection

cephalosporin group Glucocorticoids Betamethasone Parabulbar C

for local dipropionate injections

application in

ophthalmology Rehydrants Carbomer Instillations into C

conjunctival

cavity

Glucocorticoids for dexamethasone Parabulbar B

local and systemic injections,

application in intravenous

ophthalmology injections

Glucocorticoids for Prednisolone orally C

systemic

application in

ophthalmology Glucocorticoids methylprednisolone Intravenous C

for systemic injections (pulse

application in therapy)

ophthalmology

References:

1. McNab AA, McKelvie P. IgG4-Related Ophthalmic Disease. Part II: Clinical Aspects. Ophthalmic Plast Reconstr Surg. 2015 May-Jun;31(3):167-78.
2. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop. Ocul Surf. 2012;5:75–92.
3. Ervin A.M., Wojciechowski R., Schein O. Punctal occlusion for dry eye syndrome // Cochrane Database of Systematic Reviews. — 2010. — Vol. 9.
4. Kanski JJ. Acute dacryoadenitis. In: Clinical Ophthalmology. A Systematic Approach. 6th ed. Butterworth, Heineman, Elsevier; 2008:178-179.
5. Gao Y, Moonis G, Cunnane ME, Eisenberg RL. Lacrimal gland masses. AJR Am J Roentgenol. 2013 Sep;201(3):W371-81
6. Obata H, Yamagami S, Saito S, et al. A case of acute dacryoadenitis associated with herpes zoster ophthalmicus. Jpn J Ophthalmol 2003; 47:107-9.
7. Cheuk W, Yuen HK, Chan AC, Shih LY, Kuo TT, Ma MW, Lo YF, Chan WK, Chan JK. Ocular adnexal lymphoma associated with IgG4+ chronic sclerosing dacryoadenitis: a previously undescribed complication of IgG4-related sclerosing disease. Am. J. Surg. Pathol. 2008 Aug;32(8):1159-67.
8. Kiratli H, Sekeroglu MA, Soylemezoglu F. Unilateral dacryoadenitis as the sole presenting sign of Wegener's granulomatosis. Orbit 2008;27(3):157-60.
9. Madge SN, James C, Selva D. Bilateral dacryoadenitis: A new addition to the spectrum of reactive arthritis? Ophthal Plast Reconstr Surg 2009;25(2):152-3.
10. Lee S, Tsirbas A, McCann JD, et al. Mikulicz's disease: A new perspective and literature review. Eur J Ophthalmol 2006;16(2):199-203.
11. Corneal-conjunctival xerosis (diagnosis, clinical presentation, treatment) Brzheskiy V.V., Somov E.E. - 2003 - 120 p.
12. British National Formulary https://www.medicinescomplete.com
13. Mombaerts I The many facets of dacryoadenitis// Curr Opin Ophthalmol. 2015 Jul;26(5):399-407. doi: 10.1097/ICU.0000000000000183.
14. Mombaerts I, Cameron JD, Chanlalit W, Garrity JA Surgical debulking for idiopathic dacryoadenitis: a diagnosis and a cure // Ophthalmology. 2014 Feb;121(2):603-9. doi: 10.1016/j.ophtha.2013.09.010.

Indications for specialist consultations

TREATMENT TACTICS AT OUTPATIENT LEVEL: The main direction of dacryoadenitis treatment is complete resolution

of the inflammatory process of the lacrimal gland; DES – moisturizing, creating "stability" of the tear film, elimination of pathological changes associated with xerosis; epiphora – elimination of the cause that led to the appearance of tearing.

INDICATIONS FOR HOSPITALIZATION WITH INDICATION OF HOSPITALIZATION TYPE: 4.1 Indications for emergency hospitalization: none. 4.2 Indications for planned hospitalization: • Ineffectiveness of conservative therapy for dacryoadenitis

Surgical intervention (LE - B) Name of operation: Dry eye syndrome: Name of operation: • plastic surgery: closure of lacrimal punctum (ICD 9 - 09.99); • other manipulations on the lacrimal system (ICD 9 - 09.99); Indications: severe degree of dry eye syndrome

Epiphora: - Obturation of lacrimal puncta with placement of obturators. Dacryoadenitis: Orbitotomy (ICD 9 – 16.09);

Further management: • for 2 weeks to 1 month after surgery instillation of antibacterial and anti-inflammatory drugs; • in the presence of concomitant disease monitoring by a narrow specialist; • scheduled follow-up with an ophthalmologist; • compliance with appropriate therapeutic and protective regimen as indicated. 5.6 Indicators of treatment effectiveness and safety of diagnostic and treatment methods described in the protocol: • for inflammatory diseases – resolution of the inflammatory process; • for dry eye syndrome - elimination of changes associated with xerosis; • for epiphora absence of excessive tearing and lacrimation; • absence of discomfort in the eye.