Lacrimal disorders

What are lacrimal disorders?

Lacrimal disorders are problems affecting the parts of your eye that make, store or drain your tears, including your tear glands and tear ducts. They can leave your eyes dry, watery, swollen, sore or infected, depending on which part isn't working as it should.

Symptoms of lacrimal disorders

Because lacrimal disorders cover several different conditions, your symptoms will depend on which part of your tear system is affected. You might notice:

• blurred vision
• a burning, stinging or gritty feeling in your eye
• itching or sensitivity to light
• redness or swelling around your eye or eyelid
• watery eyes, with tears that come and go or never seem to stop
• a yellowish discharge
• pain, especially when you move your affected eye.

If your tear gland itself is inflamed (a condition called dacryoadenitis), you might also notice a drooping eyelid, swollen glands near your ear, and swelling specifically at the upper, outer corner of your eye, furthest from your nose.

Causes and risk factors

Infections are a common cause of lacrimal problems. Viruses such as mumps, glandular fever and adenovirus, and bacterial infections such as staph or gonorrhoea, can inflame your tear glands, usually affecting one eye at a time and clearing up once the infection is treated.

Autoimmune conditions are another cause, where your immune system mistakenly attacks your own tear glands. These include Sjögren's syndrome, thyroid eye disease, sarcoidosis and a rarer condition called granulomatosis with polyangiitis. This type tends to come back over time, is more likely to affect both eyes, and is more common in women.

Your tear drainage system can also become blocked, which is the most common cause of an infected tear sac (dacryocystitis). Elsewhere, damage to the gland itself, whether from long-term inflammation, ageing, radiotherapy, or as a reaction after a bone marrow transplant, can reduce how many tears you produce, leading to severe dry eyes.

Eye surgery to correct short-sightedness, such as LASIK, can also damage the nerves that help regulate tear production, sometimes leading to dry eyes for years afterwards.

Dacryoadenitis (tear gland inflammation) is more common in children and young adults than in people over 50, while the autoimmune-related type is more common in women.

Types of lacrimal disorders

Lacrimal disorders cover a wide range of specific conditions, and you might have more than one at once. Tear gland problems include dacryoadenitis (an inflamed tear gland) and lacrimal gland failure, where the gland doesn't make enough tears, leading to severe dry eyes.

Drainage problems include a blocked tear duct, dacryocystitis (an infected tear sac), canaliculitis (an infected drainage channel), and punctal stenosis, where the small opening that drains your tears becomes narrowed.

Eyelid conditions can also disrupt your tear film, including blepharitis (crusty, dandruff-like debris along your eyelashes), a chalazion (a small lump in an eyelid gland), trichiasis (eyelashes that turn inwards and rub on your eye), and eyelid positions that stop your eyelids closing fully or draining tears properly. Rarely, tumours can also affect the lacrimal system.

How are lacrimal disorders diagnosed?

Your doctor will usually start with a full eye examination and ask about your health history and symptoms. Depending on what they suspect, you might also need a blood test to check for infection or inflammation, or a biopsy of the tear gland.

Imaging tests such as an MRI or CT scan can help show inflammation or swelling around the gland. If a blocked tear duct is suspected, your ophthalmologist may work alongside an ear, nose and throat (ENT) specialist, who can examine inside your nose, since the tear drainage system empties there.

How are lacrimal disorders treated?

Non-surgical treatment

Treatment depends entirely on what's causing your symptoms. For infections, you'll usually need antiviral or antibiotic medicine, and it's important to finish the full course even if you feel better quickly, so the infection doesn't come back. Warm compresses can also help ease clogged glands and clear debris from your eyelashes.

If an autoimmune condition is behind your symptoms, treatment usually focuses on managing that underlying condition, sometimes with steroid medication to bring down inflammation. Over-the-counter artificial tears or a prescribed ointment can ease burning and itching, though the relief tends to be temporary.

For severe dry eyes caused by lacrimal gland failure, a different approach can help – small plugs inserted into the tiny openings that drain your tears, called punctum plugs. By blocking normal drainage, more of your own tears stay on the surface of your eye for longer.

If your tear duct is blocked, a non-invasive technique of massaging and compressing the tear sac can sometimes clear it, and this technique works for up to 90% of people. If eyelashes are rubbing on your eye, your doctor may suggest permanently removing them using electrolysis or a freezing treatment.

Surgical treatment

If simpler measures don't clear a blocked tear duct, your surgeon can pass a fine probe through the duct to open it up, sometimes leaving a temporary stent in place while it heals.

For more difficult blockages, an operation called a dacryocystorhinostomy (DCR) creates a new drainage channel from your tear sac into your nose – this can often be done as keyhole surgery through the nose itself, without any cuts to your skin.

A chalazion (a lump in an eyelid gland) can usually be drained during a short in-clinic procedure under local anaesthetic.

If your eyelids sit in the wrong position, whether turned inward, outward, or unable to close fully, surgery can usually correct this and restore normal blinking and tear drainage.

For very severe dry eyes that don't settle with punctum plugs, the tear drainage openings can also be closed surgically for a more permanent effect.

When should I see a doctor? See an eye care specialist as soon as you notice swelling, pain, discolouration or watering around your eye that does not settle, so the cause can be found and treated quickly.

Go to A&E or an emergency eye service if you have a sudden loss of vision, eye swelling that is rapidly getting worse, severe eye pain, or new flashes or floaters in your vision.